Provider Demographics
NPI:1215919907
Name:SHADRICK, SHELLY RAE (PAC)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:RAE
Last Name:SHADRICK
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 1:2500 ROCKY MOUNTAIN AVE STE 2200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9004
Mailing Address - Country:US
Mailing Address - Phone:970-669-9100
Mailing Address - Fax:970-669-0400
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE STE 2200
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9004
Practice Address - Country:US
Practice Address - Phone:970-669-9100
Practice Address - Fax:970-669-0400
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001565363A00000X, 363AM0700X, 363AS0400X
CO976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04139551Medicaid
COPOO986704OtherRAILROAD MEDICARE
COCO307646Medicare PIN