Provider Demographics
NPI:1508808031
Name:SHIRLEY, SANDRA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:SHIRLEY
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:PO BOX 20819
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89515-0819
Mailing Address - Country:US
Mailing Address - Phone:775-823-1990
Mailing Address - Fax:775-823-1974
Practice Address - Street 1:6630 S MCCARRAN BLVD
Practice Address - Street 2:SUITE B18
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6135
Practice Address - Country:US
Practice Address - Phone:775-823-1990
Practice Address - Fax:775-823-1974
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P33164Medicare UPIN