Provider Demographics
NPI:1265529796
Name:SHELLABARGER, PAUL V (PAC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:V
Last Name:SHELLABARGER
Suffix:
Gender:M
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NE
Mailing Address - Zip Code:69022-0488
Mailing Address - Country:US
Mailing Address - Phone:308-697-3317
Mailing Address - Fax:308-697-3278
Practice Address - Street 1:119 SOUTH 4TH
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:NE
Practice Address - Zip Code:69034
Practice Address - Country:US
Practice Address - Phone:308-364-9290
Practice Address - Fax:308-697-3278
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE389000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE389Medicaid
NE097529Medicare PIN
R81617Medicare UPIN