Provider Demographics
NPI:1063641298
Name:ERUOTOR, SHAHEERAH
Entity type:Individual
Prefix:
First Name:SHAHEERAH
Middle Name:
Last Name:ERUOTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-3393
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 PARK ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3393
Practice Address - Country:US
Practice Address - Phone:704-631-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19907363L00000X
NC5004431363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063641298Medicaid
SCNP3757Medicaid
NC1063641298Medicaid
SCSC78817772Medicare PIN
SCNP3757Medicaid
NCNCS011EMedicare PIN
NCNCS011BMedicare PIN
NCNCS011CMedicare PIN