Provider Demographics
NPI:1487195145
Name:ANDERSON, SHELLEY (PA-C)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 CEDAR PT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-1096
Mailing Address - Country:US
Mailing Address - Phone:678-823-5699
Mailing Address - Fax:
Practice Address - Street 1:1412 MILSTEAD AVE NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:770-918-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8319208M00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist