Provider Demographics
NPI:1275523334
Name:SHAW, DIANA (FNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2888 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:SAUQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:13456-3110
Mailing Address - Country:US
Mailing Address - Phone:315-732-0660
Mailing Address - Fax:315-737-5220
Practice Address - Street 1:2888 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:SAUQUOIT
Practice Address - State:NY
Practice Address - Zip Code:13456-3110
Practice Address - Country:US
Practice Address - Phone:315-732-0660
Practice Address - Fax:315-737-5220
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330568-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01968905Medicaid
NY01968905Medicaid