Provider Demographics
NPI:1922097161
Name:SHORES, MARY ALICE S (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY ALICE
Middle Name:S
Last Name:SHORES
Suffix:
Gender:F
Credentials:CRNP
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Mailing Address - Street 1:1380 PROGRESS WAY
Mailing Address - Street 2:SUITE 114
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6464
Mailing Address - Country:US
Mailing Address - Phone:410-795-2233
Mailing Address - Fax:410-795-3538
Practice Address - Street 1:1380 PROGRESS WAY
Practice Address - Street 2:SUITE 114
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6464
Practice Address - Country:US
Practice Address - Phone:410-795-2233
Practice Address - Fax:410-795-3538
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR124642363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD124LOtherMEDICARE GROUP #-CARROLL PRIMARY CARE-124L
MDR124642OtherSTATE OF MD
4321C731Medicare ID - Type Unspecified
MDR124642OtherSTATE OF MD