Healthcare Provider Details

I. General information

NPI: 1285492108
Provider Name (Legal Business Name): SHAKER EMERGENCY SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17201 INTERSTATE 45 S
THE WOODLANDS TX
77385-3311
US

IV. Provider business mailing address

4919 E HAZEL DR UNIT 1
PHOENIX AZ
85044-7776
US

V. Phone/Fax

Practice location:
  • Phone: 936-270-2000
  • Fax: 602-431-2149
Mailing address:
  • Phone: 602-431-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN A SORENSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-431-1152