Provider Demographics
NPI:1376544585
Name:SHORE, BRIAN NEAL (PA C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:NEAL
Last Name:SHORE
Suffix:
Gender:M
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 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-8107
Mailing Address - Fax:
Practice Address - Street 1:2110 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7553
Practice Address - Country:US
Practice Address - Phone:217-366-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL434110OtherMEDICARE GROUP
ILP00382778OtherRAILROAD MEDICARE
ILK36177Medicare PIN
Q20277Medicare UPIN
IL434110OtherMEDICARE GROUP
Q20277Medicare UPIN