Provider Demographics
NPI:1295166577
Name:SHOULDERS, RAY
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:SHOULDERS
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 1:4730 N HABANA AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614
Mailing Address - Country:US
Mailing Address - Phone:813-549-2134
Mailing Address - Fax:813-864-4436
Practice Address - Street 1:1717 PRECINCT LINE RD STE 200
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3197
Practice Address - Country:US
Practice Address - Phone:936-615-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08775363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant