Provider Demographics
NPI:1154327377
Name:SHAW, IAN WESLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:WESLEY
Last Name:SHAW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3402
Mailing Address - Country:US
Mailing Address - Phone:810-989-7429
Mailing Address - Fax:810-989-2001
Practice Address - Street 1:1002 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3402
Practice Address - Country:US
Practice Address - Phone:810-989-7429
Practice Address - Fax:810-989-2001
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIIS007218111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU61681Medicare UPIN
MI0N74460Medicare ID - Type Unspecified