Provider Demographics
NPI:1417319328
Name:HANSON, SHELBY L (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:LYNN
Other - Last Name:LAMBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002024A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant