Provider Demographics
NPI:1073058020
Name:SHAW, MICHAEL GEORGE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:SHAW
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 PEBBLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2140
Mailing Address - Country:US
Mailing Address - Phone:601-941-6897
Mailing Address - Fax:
Practice Address - Street 1:23 PEBBLE HILL DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2140
Practice Address - Country:US
Practice Address - Phone:601-941-6897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901869363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health