Healthcare Provider Details

I. General information

NPI: 1043411523
Provider Name (Legal Business Name): BRANDON CHAD SHELLEY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 FOOTHILL BLVD SUITE C
ROCK SPRINGS WY
82901-4771
US

IV. Provider business mailing address

2631 FOOTHILL BLVD SUITE C
ROCK SPRINGS WY
82901-4771
US

V. Phone/Fax

Practice location:
  • Phone: 307-362-9545
  • Fax: 307-362-9732
Mailing address:
  • Phone: 307-362-9545
  • Fax: 307-362-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2007005956
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number218
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number218
License Number StateSD
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2007005956
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number145
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: