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General NPI Number Information
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NPI Number | 1215919907
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Entity Type | Individual
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Provider Name | SHELLY RAE SHADRICK PAC
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Gender | Female
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Dates
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Enumeration Date | 11/17/2005
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Last Update Date | 10/27/2023
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Provider Practice Location Address
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Address Line | 2500 ROCKY MOUNTAIN AVE STE 2200
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City | LOVELAND
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State | CO
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Zip | 80538-9004
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Country | US
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Telephone | 970-669-9100
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Fax | 970-669-0400
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Provider Business Mailing Address
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Address Line | 2500 ROCKY MOUNTAIN AVE STE 2200
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City | LOVELAND
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State | CO
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Zip | 80538-9004
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Country | US
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Telephone | 970-669-9100
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Fax | 970-669-0400
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 001565
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 001565
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 001565
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License Number State | IA
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 976
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License Number State | CO
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