1295870210 NPI number — MS. SHANDORA ALLISA DORSE P.A.-C

Table of content: MS. SHANDORA ALLISA DORSE P.A.-C (NPI 1295870210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295870210 NPI number — MS. SHANDORA ALLISA DORSE P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORSE
Provider First Name:
SHANDORA
Provider Middle Name:
ALLISA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295870210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 LONSWAY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANTIOCH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37013-5522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-360-8852
Provider Business Mailing Address Fax Number:
615-898-5004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 GREENLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURFREESBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37132-3100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-898-2310
Provider Business Practice Location Address Fax Number:
615-898-5004
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  184 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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