Provider Demographics
NPI:1629403704
Name:SHOEMAKER, COREY L
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:L
Last Name:SHOEMAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 HIGHWAY 35 S
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-8829
Mailing Address - Country:US
Mailing Address - Phone:601-469-4771
Mailing Address - Fax:
Practice Address - Street 1:1123 HIGHWAY 35 S
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-8829
Practice Address - Country:US
Practice Address - Phone:601-469-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF0813236363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily