Provider Demographics
NPI:1972131118
Name:SHOAP, WESLEY MICHAEL
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:MICHAEL
Last Name:SHOAP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 ODONNELL ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5038
Mailing Address - Country:US
Mailing Address - Phone:484-638-1597
Mailing Address - Fax:
Practice Address - Street 1:3212 ODONNELL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5038
Practice Address - Country:US
Practice Address - Phone:484-638-1597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program