Provider Demographics
NPI:1457168304
Name:SHOOK, ANDRE
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:SHOOK
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 S AZURE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-2296
Mailing Address - Country:US
Mailing Address - Phone:714-709-1014
Mailing Address - Fax:
Practice Address - Street 1:1610 S AZURE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-2296
Practice Address - Country:US
Practice Address - Phone:714-709-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86295452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered