Provider Demographics
NPI:1497765242
Name:SHAW, MICHAEL (ARNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2038
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:12550 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3655
Practice Address - Country:US
Practice Address - Phone:239-343-9180
Practice Address - Fax:239-343-9188
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9220477363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768068600Medicaid
FLCM016XMedicare PIN
FLCM016ZMedicare PIN
FL768068600Medicaid