Provider Demographics
NPI:1972161503
Name:FELTON, SHANDA NICOLE (PA)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:NICOLE
Last Name:FELTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANDA
Other - Middle Name:NICOLE
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8 DURBIN PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-6127
Mailing Address - Country:US
Mailing Address - Phone:919-423-7128
Mailing Address - Fax:
Practice Address - Street 1:609 ATTAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1984
Practice Address - Country:US
Practice Address - Phone:919-567-0684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09102208D00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-09102OtherNORTH CAROLINA MEDICAL BOARD LICENSE