Provider Demographics
NPI:1902016652
Name:MAURICE-MAIER, SHELLEY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:MAURICE-MAIER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2597 NW CHAMPION CIR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-8692
Mailing Address - Country:US
Mailing Address - Phone:541-322-8830
Mailing Address - Fax:503-210-0503
Practice Address - Street 1:2597 NW CHAMPION CIR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-8692
Practice Address - Country:US
Practice Address - Phone:541-385-1803
Practice Address - Fax:503-210-0503
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117061Medicare PIN