Provider Demographics
NPI:1013990712
Name:DARTY, SHELLY WARREN (PAC)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:WARREN
Last Name:DARTY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 IDOL ST
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7804
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2001
Practice Address - Street 1:861 OLD WINSTON RD
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7140
Practice Address - Country:US
Practice Address - Phone:336-802-2300
Practice Address - Fax:336-802-2301
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102585363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7057773OtherAETNA
NCD7935OtherMEDCOST
NCD7935OtherMEDCOST
NCP00398019Medicare PIN
NC2762009Medicare PIN
NC7057773OtherAETNA