Provider Demographics
NPI:1700834207
Name:THIME, SHELLY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:
Last Name:THIME
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16222 W US HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-8762
Mailing Address - Country:US
Mailing Address - Phone:719-687-6022
Mailing Address - Fax:719-687-6030
Practice Address - Street 1:16222 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8762
Practice Address - Country:US
Practice Address - Phone:719-687-6022
Practice Address - Fax:719-687-6030
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40325750Medicaid
COP85638Medicare UPIN
CO40325750Medicaid