Provider Demographics
NPI:1033477757
Name:GORE, SHANDY (IDMT)
Entity Type:Individual
Prefix:MISS
First Name:SHANDY
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5610 BUNCOMBE RD APT 907
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3617
Mailing Address - Country:US
Mailing Address - Phone:318-516-9943
Mailing Address - Fax:
Practice Address - Street 1:5610 BUNCOMBE RD APT 907
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3617
Practice Address - Country:US
Practice Address - Phone:318-516-9943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians