Provider Demographics
NPI:1194759357
Name:PROCTOR, SHALLA M (PA)
Entity type:Individual
Prefix:MRS
First Name:SHALLA
Middle Name:M
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHALLA
Other - Middle Name:M
Other - Last Name:KHALIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2655 W BAKER RD
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-2206
Mailing Address - Country:US
Mailing Address - Phone:281-425-9205
Mailing Address - Fax:281-422-9408
Practice Address - Street 1:2655 W BAKER RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-2206
Practice Address - Country:US
Practice Address - Phone:281-425-9205
Practice Address - Fax:281-422-9408
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01112363A00000X
TXPA08411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant