Provider Demographics
NPI:1457842924
Name:BALLARON, SHELBY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHELBY
Middle Name:
Last Name:BALLARON
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 1:1900 E COMMERCIAL BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3746
Mailing Address - Country:US
Mailing Address - Phone:954-928-1778
Mailing Address - Fax:
Practice Address - Street 1:1900 E COMMERCIAL BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3746
Practice Address - Country:US
Practice Address - Phone:954-928-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006205363AS0400X
VA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1841550035Medicaid