Provider Demographics
NPI:1649299710
Name:SHORE, SHAUN MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:MICHAEL
Last Name:SHORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-7066
Mailing Address - Country:US
Mailing Address - Phone:469-343-6333
Mailing Address - Fax:855-299-6441
Practice Address - Street 1:960 CARIBOU DR
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-7066
Practice Address - Country:US
Practice Address - Phone:469-343-6333
Practice Address - Fax:855-299-6441
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04445363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9577OtherBCBS
TX8G6721Medicare PIN
TXQ40502Medicare UPIN