Provider Demographics
NPI:1659031078
Name:NEUROTH, SHELBY E (PAC)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:E
Last Name:NEUROTH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:E
Other - Last Name:VAN DEN BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:7727 N 88TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-5268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2725 S 144TH ST STE 212
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5253
Practice Address - Country:US
Practice Address - Phone:402-609-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-27
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA119989363A00000X
NE2714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant