Provider Demographics
NPI:1447313630
Name:SHELBY, MARLON D (PA)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:D
Last Name:SHELBY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:803-581-2800
Mailing Address - Fax:803-581-4396
Practice Address - Street 1:517 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-8644
Practice Address - Country:US
Practice Address - Phone:803-581-2800
Practice Address - Fax:803-581-4396
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104247Medicaid
SCD17688171Medicare PIN
SCD17688Medicare UPIN