Provider Demographics
NPI:1316219751
Name:SHAW, CHARLOTTE B (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:B
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5033
Mailing Address - Country:US
Mailing Address - Phone:318-281-8110
Mailing Address - Fax:318-281-8099
Practice Address - Street 1:510 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5033
Practice Address - Country:US
Practice Address - Phone:318-281-8110
Practice Address - Fax:318-281-8099
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200515363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA200515OtherPA-C
LA2316729Medicaid
LA2316729Medicaid