Provider Demographics
NPI:1700397213
Name:KIES, SHELBY LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:KIES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:LYNN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:120 E 2ND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1579
Mailing Address - Country:US
Mailing Address - Phone:814-456-8980
Mailing Address - Fax:
Practice Address - Street 1:120 E 2ND ST FL 2
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1579
Practice Address - Country:US
Practice Address - Phone:814-456-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004315363AM0700X
PAMA059461363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical