Provider Demographics
NPI:1508263161
Name:SHAW, RAYMOND (LAC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7402 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-3652
Mailing Address - Country:US
Mailing Address - Phone:703-509-7657
Mailing Address - Fax:
Practice Address - Street 1:1100 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-3902
Practice Address - Country:US
Practice Address - Phone:301-662-6478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02131171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist