Provider Demographics
NPI:1417273426
Name:SHAW, KATHY TRAN (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:TRAN
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:THI
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-2395
Mailing Address - Fax:509-865-0757
Practice Address - Street 1:3896 BEVERLY AVE NE
Practice Address - Street 2:BLDG J, SUITE 40
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1374
Practice Address - Country:US
Practice Address - Phone:503-588-0076
Practice Address - Fax:503-588-0531
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-058841207Q00000X
IL036131795207Q00000X
CAA125476207Q00000X
ORMD169036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500677323Medicaid
OR500677323Medicaid