MEDICARE: TY SHETTRON FNP

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	363LF0000X	Family Nurse Practitioner	GAA-NP001776	GA
2	363LF0000X	Family Nurse Practitioner	70369	NM
3	363LF0000X	Family Nurse Practitioner	SP032245	PA
4	363LF0000X	Family Nurse Practitioner	0024193274	VA
5	363LF0000X	Family Nurse Practitioner	0990954	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659709574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TY SHETTRON FNP

Provider Business Mailing Address
First Line	:	1144 LAKE GULCH RD
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-9743
Country	:	US
Telephone Number	:	303-328-1838
Fax Number	:

Provider Business Practice Location Address
First Line	:	1144 LAKE GULCH RD
Second Line	:
City	:	CASTLE ROCK
State	:	CO
Zip	:	80104-9743
Country	:	US
Telephone Number	:	303-328-1838
Fax Number	:

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

Provider Enumeration Date	:	11/01/2013
Last Update Date	:	12/29/2025

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