Provider Demographics
NPI:1790818557
Name:LUNG, SHELLEY M (PA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:M
Last Name:LUNG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:MARIE
Other - Last Name:MULLENNIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12020
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2020
Mailing Address - Country:US
Mailing Address - Phone:888-556-5621
Mailing Address - Fax:
Practice Address - Street 1:1700 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-526-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14745Medicaid
0PA147450Medicare ID - Type Unspecified
CAPA14745Medicaid