Provider Demographics
NPI:1861159899
Name:SOORUS, SHANE MICHAEL (APRN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:SOORUS
Suffix:
Gender:M
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 NW 100TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33150-1206
Mailing Address - Country:US
Mailing Address - Phone:269-217-3695
Mailing Address - Fax:
Practice Address - Street 1:1400 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1087
Practice Address - Country:US
Practice Address - Phone:269-217-3695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11016761363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care