Provider Demographics
NPI:1114656774
Name:PRATER, SHAWNDRICKA
Entity Type:Individual
Prefix:
First Name:SHAWNDRICKA
Middle Name:
Last Name:PRATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W SAM HOUSTON PKWY S STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2453
Mailing Address - Country:US
Mailing Address - Phone:573-838-3972
Mailing Address - Fax:
Practice Address - Street 1:123 WINKLER DR APT 42
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-1402
Practice Address - Country:US
Practice Address - Phone:573-838-3972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23006181343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)