Provider Demographics
NPI:1336688761
Name:SHAW, ALEXANDRA (LAC)
Entity Type:Individual
Prefix:MISS
First Name:ALEXANDRA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 VALETA ST UNIT 376
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5867
Mailing Address - Country:US
Mailing Address - Phone:713-870-7157
Mailing Address - Fax:
Practice Address - Street 1:3990 OLD TOWN AVE
Practice Address - Street 2:STE B107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2930
Practice Address - Country:US
Practice Address - Phone:713-870-7157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17245171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist