Healthcare Provider Details

I. General information

NPI: 1780958645
Provider Name (Legal Business Name): SHUNRIE GELDORE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NIGHTINGALE RD
EDWARDS AFB CA
93524-0001
US

IV. Provider business mailing address

30 NIGHTINGALE RD
EDWARDS AFB CA
93524-0001
US

V. Phone/Fax

Practice location:
  • Phone: 661-275-7938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: