Healthcare Provider Details

I. General information

NPI: 1215919907
Provider Name (Legal Business Name): SHELLY RAE SHADRICK PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 E KEN PRATT BLVD STE 401
LONGMONT CO
80504-5311
US

IV. Provider business mailing address

1760 E KEN PRATT BLVD STE 401
LONGMONT CO
80504-5311
US

V. Phone/Fax

Practice location:
  • Phone: 720-718-8305
  • Fax: 720-718-0955
Mailing address:
  • Phone: 720-718-8305
  • Fax: 720-718-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number976
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001565
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001565
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number001565
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: