Provider Demographics
NPI:1154503290
Name:SHARK, PETER JAMES (LAC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JAMES
Last Name:SHARK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 W GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-4556
Mailing Address - Country:US
Mailing Address - Phone:850-390-0774
Mailing Address - Fax:
Practice Address - Street 1:1215 W GARDEN ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-4556
Practice Address - Country:US
Practice Address - Phone:850-390-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11909171100000X
FL3475171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist