Healthcare Provider Details

I. General information

NPI: 1467183772
Provider Name (Legal Business Name): SHELBY MARTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2022
Last Update Date: 06/06/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 FOREST PARK AVE DIV SURG ONCOLOGY, 8TH FL
SAINT LOUIS MO
63108-2114
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-2280
  • Fax: 888-352-8360
Mailing address:
  • Phone: 314-362-2280
  • Fax: 888-352-8360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2025010660
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: