Samuel Mark Shores, FNP-BC

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

5015329 Issued in NC

Practice address

630 Matthews Township Pkwy
Matthews, NC 28105-5322

Phone

(704) 495-6020

Fax

(844) 620-0793

NPI assigned

Sep 28, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: samuel.shores.1@12616.direct.athenahealth.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Amity Medical Group, Inc.

  • Federally Qualified Health Center (FQHC)
  • Charlotte, NC
  • NPI 1003301300
  Medicare reassignment NPD
• Monogram Health Professional Services of North Carolina PC

  • Nephrology Physician
  • Winston Salem, NC
  • NPI 1366162885

  Family

  Medicare reassignment NPD
• Tryon Medical Partners, PLLC

  • Internal Medicine Physician
  • Charlotte, NC
  • NPI 1992204549
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1632787200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1674777600000",
    "number": "1992477020",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5960 FAIRVIEW RD STE 500",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282103113",
            "telephone_number": "704-495-6324"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "630 MATTHEWS TOWNSHIP PKWY",
            "city": "MATTHEWS",
            "state": "NC",
            "postal_code": "281055322",
            "telephone_number": "704-495-6020",
            "fax_number": "844-620-0793"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SHORES",
        "first_name": "SAMUEL",
        "middle_name": "MARK",
        "name_prefix": "Mr.",
        "credential": "FNP-BC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-09-28",
        "last_updated": "2023-01-27",
        "certification_date": "2023-01-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NC",
            "license": "5015329",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "5015329",
            "identifier": "1992477020",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kaitlyn Marie Shelton, PA-C
• Keithe Saclayan Shensky, MD
• Kayla Shephard, FNP
• Sheryl Reto, LCSW, PLLC
• Yukino Yamada Shope, CNM
• Brandy Shott, LCMHCA, NCC
• Jay Shukla, DMD
• Michelle Siegel, LCSW
• Justin Sigler, PHARMD
• Michelle Sigler, L.AC.

• Family Nurse Practitioner in Matthews, NC
• Providers in Matthews, NC by specialty
• Family Nurse Practitioner in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.