Provider Demographics
NPI:1376840587
Name:SHAW, COLLEEN R (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 JACKSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-675-5555
Mailing Address - Fax:307-675-5599
Practice Address - Street 1:916 JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-675-5555
Practice Address - Fax:307-675-5599
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA114032208000000X
WYTL4426208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics