Provider Demographics
NPI:1720396872
Name:GAUM, SHELLEY AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:AMBER
Last Name:GAUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:AMBER
Other - Last Name:RICHARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:888-239-8370
Mailing Address - Fax:
Practice Address - Street 1:401 DIVISION ST STE 306
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1455
Practice Address - Country:US
Practice Address - Phone:304-766-4300
Practice Address - Fax:304-766-5474
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01513363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1720396872Medicaid