Provider Demographics
NPI:1972608511
Name:SHOGREN, PAUL LESLIE (DC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LESLIE
Last Name:SHOGREN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 S FRONTAGE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2571
Mailing Address - Country:US
Mailing Address - Phone:218-233-8544
Mailing Address - Fax:218-233-8545
Practice Address - Street 1:2921 S FRONTAGE RD STE 3
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2571
Practice Address - Country:US
Practice Address - Phone:218-233-8544
Practice Address - Fax:218-233-8545
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN954827100Medicaid
ND14258Medicaid
MN954827100Medicaid
MNT70853Medicare UPIN