Provider Demographics
NPI:1063632297
Name:SHOOK, TERESA (LSA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:SHOOK
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 295305
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75029-5305
Mailing Address - Country:US
Mailing Address - Phone:214-771-6205
Mailing Address - Fax:
Practice Address - Street 1:4401 BOOTH CALLOWAY RD
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-7371
Practice Address - Country:US
Practice Address - Phone:214-771-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA000146246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0017JROtherBCBS
TXSA00146OtherLICENSED SURGICAL ASST