Basic Information
Provider Information | |||||||||
NPI: | 1275783706 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAPIRO | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3540 WINDSOR DR | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165062219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6303355718 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 232 W 25TH ST | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165441463 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144525101 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2008 | ||||||||
LastUpdateDate: | 05/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | HS000220L | PA | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.