Healthcare Provider Details

I. General information

NPI: 1346130184
Provider Name (Legal Business Name): TORI SHADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 KENDALL DR
SAN BERNARDINO CA
92407-4156
US

IV. Provider business mailing address

941 KENDALL DR STE C
SAN BERNARDINO CA
92407-4156
US

V. Phone/Fax

Practice location:
  • Phone: 909-726-3200
  • 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: