Provider Demographics
NPI:1043957582
Name:STOCKTON, SHELBY GLYNN
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:GLYNN
Last Name:STOCKTON
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 1:22521 SPORTSMAN RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16434-3343
Mailing Address - Country:US
Mailing Address - Phone:412-584-0730
Mailing Address - Fax:
Practice Address - Street 1:800 PLAZA DR STE 140
Practice Address - Street 2:
Practice Address - City:ROSTRAVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15012-4019
Practice Address - Country:US
Practice Address - Phone:724-929-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMA063933363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program