Provider Demographics
NPI:1902622087
Name:LONG, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10704 TROPHY CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-2561
Mailing Address - Country:US
Mailing Address - Phone:512-944-7157
Mailing Address - Fax:
Practice Address - Street 1:1111 W 34TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1916
Practice Address - Country:US
Practice Address - Phone:512-324-3405
Practice Address - Fax:512-324-3404
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002022363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner