Provider Demographics
NPI:1760416572
Name:DOLKAS LICKL, SHELLEY (PA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:DOLKAS LICKL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5445
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5445
Mailing Address - Country:US
Mailing Address - Phone:714-637-4307
Mailing Address - Fax:714-282-9115
Practice Address - Street 1:1 HOAG DR
Practice Address - Street 2:ECU
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17133Medicaid
CAWPA17133AMedicare PIN
Q10806Medicare UPIN