Provider Demographics
NPI:1659382810
Name:SHELBY, WADE H (PT)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:H
Last Name:SHELBY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4649 GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-3506
Mailing Address - Country:US
Mailing Address - Phone:432-366-9541
Mailing Address - Fax:432-366-1951
Practice Address - Street 1:4407 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5311
Practice Address - Country:US
Practice Address - Phone:432-366-9541
Practice Address - Fax:432-366-1951
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1093102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B2471Medicare ID - Type Unspecified