Provider Demographics
NPI:1497792667
Name:SHAW, ELLEN A (PNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:PNP
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Other - Last Name:
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Mailing Address - Street 1:3959 BROADWAY
Mailing Address - Street 2:COLUMBIA UNVERSITY DEPARTMENT PEDIATRIC
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1559
Mailing Address - Country:US
Mailing Address - Phone:212-304-7250
Mailing Address - Fax:212-544-1974
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:COLUMBIA UNVERSITY DEPARTMENT PEDIATRIC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-304-7250
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF3810081363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02752129Medicaid
NJ0105678Medicaid
NY02752129Medicaid
NY1734G1Medicare ID - Type Unspecified