Provider Demographics
NPI:1033390398
Name:SHETLEY, CARSON ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:ELIZABETH
Last Name:SHETLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP STE 105
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5718
Mailing Address - Country:US
Mailing Address - Phone:318-212-3520
Mailing Address - Fax:318-212-3525
Practice Address - Street 1:1666 E BERT KOUNS INDUSTRIAL LOOP STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5718
Practice Address - Country:US
Practice Address - Phone:318-212-3520
Practice Address - Fax:318-212-3525
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07206363AM0700X
LAPA200181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1157872Medicaid
LA1157872Medicaid