Provider Demographics
NPI:1154571149
Name:WARD, SHELLY J (PAC)
Entity type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:J
Last Name:WARD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:J
Other - Last Name:TULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:6318 FM 1488 RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-2763
Mailing Address - Country:US
Mailing Address - Phone:936-321-3110
Mailing Address - Fax:
Practice Address - Street 1:6318 FM 1488 RD
Practice Address - Street 2:SUITE #100
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-2763
Practice Address - Country:US
Practice Address - Phone:936-321-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04699363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P2140OtherBLUE CROSS BLUE SHIELD
TXMT1111513OtherDEA
TXI11199Medicare UPIN