Healthcare Provider Details

I. General information

NPI: 1659315448
Provider Name (Legal Business Name): ROBIN R SHELLITO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 CEMETERY ROAD MEDICAL ASSOCIATES OF SARDIS
SARDIS GA
30456
US

IV. Provider business mailing address

305 JONES AVE
WAYNESBORO GA
30830-1510
US

V. Phone/Fax

Practice location:
  • Phone: 478-569-9600
  • Fax: 478-569-4999
Mailing address:
  • Phone: 706-554-5147
  • Fax: 706-554-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: