Healthcare Provider Details

I. General information

NPI: 1487892386
Provider Name (Legal Business Name): SHELLEY IRVING PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 W 2ND ST
MOREHEAD KY
40351-1550
US

IV. Provider business mailing address

316 W 2ND ST
MOREHEAD KY
40351-1550
US

V. Phone/Fax

Practice location:
  • Phone: 606-784-3771
  • Fax: 606-783-6847
Mailing address:
  • Phone: 606-784-3771
  • Fax: 606-783-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: