Provider Demographics
NPI:1902212426
Name:DANIELS, SHELLY R (PA C)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:R
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:R
Other - Last Name:ALDRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3173 43RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-478-8780
Mailing Address - Fax:
Practice Address - Street 1:3173 43RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-478-8780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3333-23363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical