Provider Demographics
NPI:1154494029
Name:SHAW, DEBRA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10973 233RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 WEST 66TH STREET
Practice Address - Street 2:SUITE 290
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-914-1882
Practice Address - Fax:952-914-1727
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR144120-2363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6409270-00Medicaid
MN500004309OtherMEDICARE