Healthcare Provider Details

I. General information

NPI: 1629972823
Provider Name (Legal Business Name): BRIAN D SHELBURNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 N MODOC AVE UNIT 55
MEDFORD OR
97504-3696
US

IV. Provider business mailing address

1224 N MODOC AVE UNIT 55
MEDFORD OR
97504-3696
US

V. Phone/Fax

Practice location:
  • Phone: 541-646-0454
  • Fax:
Mailing address:
  • Phone: 541-646-0454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberM5067944
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: