Provider Demographics
NPI:1871694463
Name:NAOMI, SHELLEY (PAC)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:NAOMI
Suffix:
Gender:F
Credentials:PAC
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 912491
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2491
Mailing Address - Country:US
Mailing Address - Phone:307-773-8133
Mailing Address - Fax:307-432-3618
Practice Address - Street 1:160 HERITAGE WAY STE 202
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3127
Practice Address - Country:US
Practice Address - Phone:406-752-8433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT26604363A00000X
WI1935363A00000X
WY464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42882400Medicaid
WI031720270Medicare ID - Type Unspecified
P50440Medicare UPIN