Provider Demographics
NPI:1093440562
Name:SHAW, RICKEY
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:
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 1:4550 W OAKEY BLVD STE 101A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1506
Mailing Address - Country:US
Mailing Address - Phone:792-343-9590
Mailing Address - Fax:702-463-4348
Practice Address - Street 1:4550 W OAKEY BLVD STE 101A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1506
Practice Address - Country:US
Practice Address - Phone:792-343-9590
Practice Address - Fax:702-463-4348
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant