Healthcare Provider Details

I. General information

NPI: 1790818557
Provider Name (Legal Business Name): SHELLEY M LUNG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY MARIE MULLENNIX

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 COFFEE RD
MODESTO CA
95355-2803
US

IV. Provider business mailing address

PO BOX 12020
WESTMINSTER CA
92685-2020
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4500
  • Fax:
Mailing address:
  • Phone: 888-556-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: