Provider Demographics
NPI:1356805394
Name:SHELTON, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 W JORDAN ST
Mailing Address - Street 2:STE 1E
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1734
Mailing Address - Country:US
Mailing Address - Phone:850-434-0077
Mailing Address - Fax:850-434-0220
Practice Address - Street 1:904 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506-3820
Practice Address - Country:US
Practice Address - Phone:850-434-0077
Practice Address - Fax:850-434-0220
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001048363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty