Provider Demographics
NPI:1780863068
Name:SHULSE, JOHN R
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:SHULSE
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 1:721 WOODLAND FOREST CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-8832
Mailing Address - Country:US
Mailing Address - Phone:910-632-8534
Mailing Address - Fax:910-442-1199
Practice Address - Street 1:1602 PHYSICIANS DR STE 104
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7350
Practice Address - Country:US
Practice Address - Phone:910-442-1100
Practice Address - Fax:910-442-1199
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15959367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered