Provider Demographics
NPI:1063403269
Name:SHELTON, HEATHER A (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:SHELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22666
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-2666
Mailing Address - Country:US
Mailing Address - Phone:928-768-3445
Mailing Address - Fax:928-788-4239
Practice Address - Street 1:3015 HWAY 95
Practice Address - Street 2:# 109
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-4334
Practice Address - Country:US
Practice Address - Phone:928-763-5055
Practice Address - Fax:928-763-5056
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ239132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ403395Medicaid
AZ403395Medicaid
AZZ118320Medicare PIN