Basic Information
| Provider Information | |||||||||
| NPI: | 1366635658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORE | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4645 PARK DR | ||||||||
| Address2: | APT C | ||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920084248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604762953 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6260 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920091609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604762953 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A7172 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20A7172 | 01 | CA | LICENSE NUMBER | OTHER |