Provider Demographics
NPI:1063499663
Name:SHAW, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6465 WAYZATA BLVD
Mailing Address - Street 2:STE 315
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:952-993-7169
Mailing Address - Fax:952-993-0300
Practice Address - Street 1:3800 PARK NICOLLET BLVD
Practice Address - Street 2:PARK NICOLLET CLINIC - GASTRO
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-3240
Practice Address - Fax:952-993-1865
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN25905207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology