Provider Demographics
NPI:1417338724
Name:PENDERGRASS, SHELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17075 FOX RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4834
Mailing Address - Country:US
Mailing Address - Phone:225-235-6696
Mailing Address - Fax:
Practice Address - Street 1:217 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-2527
Practice Address - Country:US
Practice Address - Phone:225-473-3931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200820363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical