Provider Demographics
NPI:1568670008
Name:SHURA, KELLY LYNN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:SHURA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:PA
Mailing Address - Zip Code:16686-6823
Mailing Address - Country:US
Mailing Address - Phone:814-312-6831
Mailing Address - Fax:
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601
Practice Address - Country:US
Practice Address - Phone:814-889-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant