Provider Demographics
NPI:1376045054
Name:SHAW, JUSTIN TYLER (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:SHAW
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 AMESBURY LN
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-3803
Mailing Address - Country:US
Mailing Address - Phone:972-922-4991
Mailing Address - Fax:
Practice Address - Street 1:368 N GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-2232
Practice Address - Country:US
Practice Address - Phone:972-396-6975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X, 390200000X
TXAT77902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program