Provider Demographics
NPI:1790732493
Name:SHATLEY, MISTY L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:L
Last Name:SHATLEY
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 1:225 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3119
Mailing Address - Country:US
Mailing Address - Phone:870-207-1630
Mailing Address - Fax:870-207-6581
Practice Address - Street 1:225 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3119
Practice Address - Country:US
Practice Address - Phone:870-207-1630
Practice Address - Fax:870-207-6581
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P68564Medicare UPIN