Healthcare Provider Details

I. General information

NPI: 1336184308
Provider Name (Legal Business Name): SHELLEY J HANCOCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 S NATIONAL AVE SUITE 600
SPRINGFIELD MO
65807-5287
US

IV. Provider business mailing address

1338 E COMPTON ST
SPRINGFIELD MO
65804-4248
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-4880
  • Fax:
Mailing address:
  • Phone: 417-887-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: