Provider Demographics
NPI:1891364154
Name:FUGATE, SHELBY (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:FUGATE
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 1:2101 JACKSON ST STE 205
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4387
Mailing Address - Country:US
Mailing Address - Phone:765-683-3160
Mailing Address - Fax:765-646-8367
Practice Address - Street 1:2101 JACKSON ST STE 205
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4387
Practice Address - Country:US
Practice Address - Phone:765-683-3160
Practice Address - Fax:765-646-8367
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003282A363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant