Provider Demographics
NPI:1639538473
Name:SHIRLEY, MARY BETH (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 OAK HILL DR
Mailing Address - Street 2:
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-2383
Mailing Address - Country:US
Mailing Address - Phone:731-925-2300
Mailing Address - Fax:731-645-1019
Practice Address - Street 1:181 S Y SQ
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1739
Practice Address - Country:US
Practice Address - Phone:731-925-2300
Practice Address - Fax:731-645-1019
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant