Provider Demographics
NPI:1760496533
Name:SHELTON, RYAN R (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:R
Last Name:SHELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 18TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-232-7760
Mailing Address - Fax:208-232-1950
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257177207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology