Provider Demographics
NPI:1275783912
Name:SHAW, LESLIE A (RD, LD, PA-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:RD, LD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 COLUMBIA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-7215
Mailing Address - Country:US
Mailing Address - Phone:440-808-1212
Mailing Address - Fax:
Practice Address - Street 1:32800 LORAIN RD STE 2300
Practice Address - Street 2:
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3430
Practice Address - Country:US
Practice Address - Phone:440-406-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6251133V00000X
OH50.005005RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0217187Medicaid