Provider Demographics
NPI:1366164535
Name:MODEROW, SHELBY MARYANN
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:MARYANN
Last Name:MODEROW
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 1:1425 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2734
Mailing Address - Country:US
Mailing Address - Phone:701-371-3519
Mailing Address - Fax:
Practice Address - Street 1:7321 BALMER ST # 570
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-586-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical