Provider Demographics
NPI:1114493756
Name:SHAW, DANIEL S (ACNP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:SHAW
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-0689
Mailing Address - Country:US
Mailing Address - Phone:931-722-2800
Mailing Address - Fax:931-722-9627
Practice Address - Street 1:107 JV MANGUBAT DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2440
Practice Address - Country:US
Practice Address - Phone:931-722-2800
Practice Address - Fax:931-722-9627
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24734363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology