Provider Demographics
NPI:1407094667
Name:STATES, SHELLY MARGARET (PA)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:MARGARET
Last Name:STATES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21542 HAWKSPUR RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-5259
Mailing Address - Country:US
Mailing Address - Phone:832-397-9283
Mailing Address - Fax:
Practice Address - Street 1:1353 N TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:TX
Practice Address - Zip Code:77575-3549
Practice Address - Country:US
Practice Address - Phone:832-397-9283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02525363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02525OtherPHYSICIAN ASSISTANT LICENSE