Provider Demographics
NPI:1568146249
Name:SHAW, RYAN T
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:T
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 TULSA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-2242
Mailing Address - Country:US
Mailing Address - Phone:978-944-4023
Mailing Address - Fax:
Practice Address - Street 1:588 LONGMEADOW ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-2212
Practice Address - Country:US
Practice Address - Phone:978-944-4023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program