Provider Demographics
NPI:1811439979
Name:LUEPHANG, SHELLEY (PA)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:
Last Name:LUEPHANG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8515 OOLTEWAH GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-9581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8515 OOLTEWAH GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-9581
Practice Address - Country:US
Practice Address - Phone:423-580-4092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1811439979Medicaid