Provider Demographics
NPI:1124251103
Name:SHELTON, MICHAEL TYSHUNE (RN, MSN)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TYSHUNE
Last Name:SHELTON
Suffix:
Gender:M
Credentials:RN, MSN
Other - Prefix:
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Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-922-7000
Mailing Address - Fax:210-227-0282
Practice Address - Street 1:829 GOETHALS DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3529
Practice Address - Country:US
Practice Address - Phone:509-547-2204
Practice Address - Fax:509-542-8836
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRN 794786163W00000X
WAAP61096750363L00000X, 363LF0000X
TXF1009375 NP-C363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX338696301Medicaid