Provider Demographics
NPI:1275768673
Name:SHIVELY, SARA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ELIZABETH
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:PA-C
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 1328
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-1328
Mailing Address - Country:US
Mailing Address - Phone:970-335-2342
Mailing Address - Fax:
Practice Address - Street 1:52 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8368
Practice Address - Country:US
Practice Address - Phone:970-264-2104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-29
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003685363A00000X
VA363A00000X
NMPA2015-0097363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16531779Medicaid