Healthcare Provider Details

I. General information

NPI: 1396399861
Provider Name (Legal Business Name): SHELBY KOTULEK FREELAND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELBY ROSE MARIE KOTULEK

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W MAIN ST
EDNA TX
77957-2454
US

IV. Provider business mailing address

PO BOX 22239
NEW YORK NY
10087-0001
US

V. Phone/Fax

Practice location:
  • Phone: 361-782-7614
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12943
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: