Provider Demographics
NPI:1255924064
Name:TIEKEN, SHELBY RIGDON (AGACNP-BC)
Entity type:Individual
Prefix:MR
First Name:SHELBY
Middle Name:RIGDON
Last Name:TIEKEN
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W MAGNOLIA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7657
Mailing Address - Country:US
Mailing Address - Phone:817-702-2977
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1028643363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care