Provider Demographics
NPI:1114434990
Name:SHORE, ETHEL CAROLINE (PA-C)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:CAROLINE
Last Name:SHORE
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 1:3150 ROGERS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4196
Mailing Address - Country:US
Mailing Address - Phone:919-504-4000
Mailing Address - Fax:984-235-1250
Practice Address - Street 1:3150 ROGERS RD STE 101
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:919-504-4000
Practice Address - Fax:984-235-1250
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07550207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine