Provider Demographics
NPI:1396843421
Name:SHORE, HEIDI (PA)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:
Last Name:SHORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:ROBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:244 96 61 AVENUE DOUGLASTON NY 11362
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362
Mailing Address - Country:US
Mailing Address - Phone:718-968-1515
Mailing Address - Fax:718-209-2295
Practice Address - Street 1:5000 AVENUE K
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234
Practice Address - Country:US
Practice Address - Phone:718-968-1515
Practice Address - Fax:718-209-2295
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002629363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00203892Medicaid
NPP000Medicare UPIN
NY00203892Medicaid