Provider Demographics
NPI:1669258828
Name:NOVETSKY, SHELBY (PA-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:NOVETSKY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:SUSELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:601 JOHN STREET
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5973 BEATRICE DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-9583
Practice Address - Country:US
Practice Address - Phone:269-286-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant