=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437522638
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELA TOWANNA MAINOR PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2015
-----------------------------------------------------
Last Update Date | 06/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 ROCKVILLE PIKE
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-1133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-424-0658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10213 WASHINGTONIAN BLVD APT 574
-----------------------------------------------------
City | GAITHERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20878-8336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-248-2346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA9109488
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | C06005
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------