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General NPI Number Information
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NPI Number | 1407094667
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Entity Type | Individual
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Provider Name | SHELLY MARGARET STATES P.A
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Gender | Female
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Dates
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Enumeration Date | 01/27/2009
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Last Update Date | 11/27/2012
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Provider Practice Location Address
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Address Line | 1353 N TRAVIS ST
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City | LIBERTY
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State | TX
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Zip | 77575-3549
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Country | US
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Telephone | 832-397-9283
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Fax |
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Provider Business Mailing Address
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Address Line | 21542 HAWKSPUR RIDGE ST
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City | RICHMOND
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State | TX
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Zip | 77406-5259
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Country | US
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Telephone | 832-397-9283
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA02525
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License Number State | TX
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