Provider Demographics
NPI:1265617013
Name:MYERS, SHELLY R (DO)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:MYERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 N 12TH ST
Mailing Address - Street 2:SUITE #103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4233
Mailing Address - Country:US
Mailing Address - Phone:602-753-2345
Mailing Address - Fax:855-588-4647
Practice Address - Street 1:4520 N 12TH ST
Practice Address - Street 2:SUITE #103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4233
Practice Address - Country:US
Practice Address - Phone:602-753-2345
Practice Address - Fax:855-588-4647
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005397207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine