Provider Demographics
NPI:1831875426
Name:GUSTIN, SHELBY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:ANN
Last Name:GUSTIN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:ANN
Other - Last Name:BONNEMIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3308 SAMSON WAY STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-3235
Practice Address - Country:US
Practice Address - Phone:402-291-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA129662363A00000X
NE3194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program