Provider Demographics
NPI:1285184002
Name:SHAW, ANDREW (LMP)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 NE 138TH AVE APT 53
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-7290
Mailing Address - Country:US
Mailing Address - Phone:360-713-8283
Mailing Address - Fax:
Practice Address - Street 1:1436 NW BENTON ST
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-1542
Practice Address - Country:US
Practice Address - Phone:240-217-5538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60594167171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor