MEDICARE: KRISTY SHELLENBERGER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	OA002088	PA
2	363AM0700X	Medical Physician Assistant	MA051755	PA

General Provider Information

NPI Number	:	1396992251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY SHELLENBERGER PA-C

Provider Business Mailing Address
First Line	:	3380 MEMPHIS ST
Second Line	:	MEMPHIS STREET PEDIATRICS
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-4510
Country	:	US
Telephone Number	:	215-426-5566
Fax Number	:	215-739-7304

Provider Business Practice Location Address
First Line	:	3380 MEMPHIS ST
Second Line	:	MEMPHIS STREET PEDIATRICS
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-4510
Country	:	US
Telephone Number	:	215-426-5566
Fax Number	:	215-739-7304

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2008
Last Update Date	:	08/22/2008

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