Healthcare Provider Details

I. General information

NPI: 1508222084
Provider Name (Legal Business Name): SHANE A CORDREY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28780 SINGLE OAK DR STE 260
TEMECULA CA
92590-5534
US

IV. Provider business mailing address

28780 SINGLE OAK DR STE 260
TEMECULA CA
92590-5534
US

V. Phone/Fax

Practice location:
  • Phone: 951-676-4193
  • Fax:
Mailing address:
  • Phone: 951-676-4193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54923
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2936
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: