Provider Demographics
NPI:1457894081
Name:SHOR, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SHOR
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 1:44 PADDOCK PL
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-5329
Mailing Address - Country:US
Mailing Address - Phone:304-997-4161
Mailing Address - Fax:
Practice Address - Street 1:44 PADDOCK PL
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-5329
Practice Address - Country:US
Practice Address - Phone:304-997-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2002-1082225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist