Provider Demographics
NPI:1336814938
Name:KING, SHELBY SMITH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:SMITH
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHELBY
Other - Middle Name:NICOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 ACORN OAKS CIR APT 113
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-2086
Mailing Address - Country:US
Mailing Address - Phone:770-715-7367
Mailing Address - Fax:
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical