Provider Demographics
NPI:1619254489
Name:SHAW, JOHN ERIC (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ERIC
Last Name:SHAW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1184
Mailing Address - Country:US
Mailing Address - Phone:304-265-2191
Mailing Address - Fax:304-265-2194
Practice Address - Street 1:500 MARKET ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1184
Practice Address - Country:US
Practice Address - Phone:304-265-2191
Practice Address - Fax:304-265-2194
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1157225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0157012000Medicaid