Provider Demographics
NPI:1346439049
Name:SHELTON, GARY (PTA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-0435
Mailing Address - Country:US
Mailing Address - Phone:270-556-3842
Mailing Address - Fax:
Practice Address - Street 1:606 E SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3227
Practice Address - Country:US
Practice Address - Phone:321-727-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13961225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant