Provider Demographics
NPI:1275772667
Name:SHAW, REBECCA D (CFA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:SHAW
Suffix:
Gender:F
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 E LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7975
Mailing Address - Country:US
Mailing Address - Phone:208-377-9515
Mailing Address - Fax:
Practice Address - Street 1:3630 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7975
Practice Address - Country:US
Practice Address - Phone:208-377-9515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-81892086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDH44448Medicare UPIN
1100368Medicare Oscar/Certification
ID1100368Medicare PIN