Provider Demographics
NPI:1134598501
Name:KING, SHELBY BOGGUS (PA-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:BOGGUS
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:VIRGINIA
Other - Last Name:BOGGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4181 HOSPITAL DR NE STE 204
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2541
Mailing Address - Country:US
Mailing Address - Phone:770-788-6534
Mailing Address - Fax:
Practice Address - Street 1:4181 HOSPITAL DRIVE NE
Practice Address - Street 2:SUITE 204
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014
Practice Address - Country:US
Practice Address - Phone:770-788-6534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7686363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical