Provider Demographics
NPI:1477546489
Name:SHAW-GRANT, PAMELA G (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:G
Last Name:SHAW-GRANT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CLEAR CRK
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:AL
Mailing Address - Zip Code:36856-4433
Mailing Address - Country:US
Mailing Address - Phone:706-464-7745
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-323-0174
Practice Address - Fax:706-256-3264
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN070808163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP29280Medicare UPIN