Provider Demographics
NPI:1477899441
Name:KETRON, SHELLY RICHARDS (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RICHARDS
Last Name:KETRON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:RICHARDS
Other - Last Name:BELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:
Practice Address - Street 1:2050 MEADOWVIEW PKWY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7475
Practice Address - Country:US
Practice Address - Phone:423-230-5000
Practice Address - Fax:423-390-6852
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03974363A00000X
TN2998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I970884Medicare PIN