Provider Demographics
NPI:1992477020
Name:SHORES, SAMUEL MARK (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:MARK
Last Name:SHORES
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6324
Mailing Address - Fax:
Practice Address - Street 1:630 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5322
Practice Address - Country:US
Practice Address - Phone:704-495-6020
Practice Address - Fax:844-620-0793
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992477020Other5015329