Provider Demographics
NPI:1376783324
Name:SHAW, RENITA TA'SHA (DPM)
Entity Type:Individual
Prefix:DR
First Name:RENITA
Middle Name:TA'SHA
Last Name:SHAW
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:RENITA
Other - Middle Name:TA'SHA
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1434 E CENTRAL AVE.
Mailing Address - Street 2:STONE COUNTY HOSPITAL
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39503
Mailing Address - Country:US
Mailing Address - Phone:601-928-6700
Mailing Address - Fax:601-928-6731
Practice Address - Street 1:1434 CENTRAL AVE E
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-9602
Practice Address - Country:US
Practice Address - Phone:601-928-6700
Practice Address - Fax:601-928-6731
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80199213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery