Provider Demographics
NPI:1235235953
Name:SHAW, TIMOTHY J (DC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
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 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-2526
Mailing Address - Fax:
Practice Address - Street 1:522 HEWETT ST
Practice Address - Street 2:
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1926
Practice Address - Country:US
Practice Address - Phone:715-743-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2231-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38798300Medicaid
T63316Medicare UPIN
WI000170255Medicare ID - Type Unspecified