Provider Demographics
NPI:1942074711
Name:BENNETT, SHELBY LEIGH (PA)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEIGH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 SW K ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1046
Mailing Address - Country:US
Mailing Address - Phone:503-506-0474
Mailing Address - Fax:
Practice Address - Street 1:83 SW K ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1046
Practice Address - Country:US
Practice Address - Phone:503-506-0474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64972363AM0700X
390200000X
ORPA222574363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program