Provider Demographics
NPI:1306309083
Name:SHELSTAD, JAMIE PEPI (PA-S)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:PEPI
Last Name:SHELSTAD
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 STUART ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-7539
Mailing Address - Country:US
Mailing Address - Phone:303-718-1646
Mailing Address - Fax:
Practice Address - Street 1:2501 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3813
Practice Address - Country:US
Practice Address - Phone:270-575-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2522363A00000X
390200000X
CO1157375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program