Provider Demographics
NPI:1235564402
Name:SHAW, KATHERINE ROSE (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:ROSE
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 1:18161 W 13 MILE RD
Mailing Address - Street 2:SUITE E1
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1113
Mailing Address - Country:US
Mailing Address - Phone:248-642-8989
Mailing Address - Fax:
Practice Address - Street 1:19933 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1024
Practice Address - Country:US
Practice Address - Phone:248-203-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269149363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health