Provider Demographics
NPI:1336683812
Name:SHAW, DEBRA (ANP-BC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2935
Mailing Address - Country:US
Mailing Address - Phone:314-647-2200
Mailing Address - Fax:314-674-4172
Practice Address - Street 1:2340 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2935
Practice Address - Country:US
Practice Address - Phone:314-647-2200
Practice Address - Fax:314-674-4172
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133017163W00000X
MO2016041524363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse