Provider Demographics
NPI:1083915201
Name:SHADE, LAURA J (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:SHADE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:WHEELING HOSPITAL
Practice Address - Street 2:1 MEDICAL PARK
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-3000
Practice Address - Fax:304-243-3060
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN28193093363LN0000X
IN71004167363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201005360Medicaid