Healthcare Provider Details

I. General information

NPI: 1467491258
Provider Name (Legal Business Name): CYNTHIA JAYNE SHALBY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E WASHINGTON BLVD SUITE 100
CRESCENT CITY CA
95531-8160
US

IV. Provider business mailing address

550 E WASHINGTON BLVD SUITE 100
CRESCENT CITY CA
95531-8160
US

V. Phone/Fax

Practice location:
  • Phone: 707-826-8633
  • Fax:
Mailing address:
  • Phone: 707-826-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1646
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1500388
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: