Provider Demographics
NPI:1437522638
Name:MAINOR, SHELA TOWANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELA
Middle Name:TOWANNA
Last Name:MAINOR
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 1:4201 BELFORT RD
Mailing Address - Street 2:ST. VINCENT'S MEDICAL CENTER SOUTHSIDE
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1431
Mailing Address - Country:US
Mailing Address - Phone:912-248-2346
Mailing Address - Fax:
Practice Address - Street 1:4201 BELFORT RD
Practice Address - Street 2:ST. VINCENT'S MEDICAL CENTER SOUTHSIDE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1431
Practice Address - Country:US
Practice Address - Phone:912-248-2346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06005363AM0700X
FLPA9109488363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical