Provider Demographics
NPI:1538123278
Name:SHELLEY, IAN R (MSPT)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:R
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 W FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-3935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 E MARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-2160
Practice Address - Country:US
Practice Address - Phone:717-242-4840
Practice Address - Fax:717-242-4841
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT012688225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001824360Medicaid
PAP22604Medicare UPIN
PA001824360Medicaid