Provider Demographics
NPI:1992568737
Name:HORTON, SHANE ELLISON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ELLISON
Last Name:HORTON
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 1:1551 JANMAR RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5606
Mailing Address - Country:US
Mailing Address - Phone:678-344-8900
Mailing Address - Fax:
Practice Address - Street 1:1371 CHURCH STREET EXT NE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7913
Practice Address - Country:US
Practice Address - Phone:678-931-8091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12133363AS0400X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208800000XAllopathic & Osteopathic PhysiciansUrology