Provider Demographics
NPI:1659709574
Name:SHETTRON, TY (FNP)
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:
Last Name:SHETTRON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81073-1622
Mailing Address - Country:US
Mailing Address - Phone:719-523-6628
Mailing Address - Fax:719-523-4513
Practice Address - Street 1:900 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:CO
Practice Address - Zip Code:81073-1636
Practice Address - Country:US
Practice Address - Phone:719-523-6628
Practice Address - Fax:719-523-4513
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0990954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89279077Medicaid