Provider Demographics
NPI:1619586518
Name:ANDERSON-SHAW, LISA K (APN, BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:ANDERSON-SHAW
Suffix:
Gender:F
Credentials:APN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E WATERSIDE DR UNIT 3910
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-8026
Mailing Address - Country:US
Mailing Address - Phone:312-636-4908
Mailing Address - Fax:
Practice Address - Street 1:MACNEAL TRINITY MEDICAL CETNER
Practice Address - Street 2:3249 OAK PARK AVENUE
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-738-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001980174V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174V00000XOther Service ProvidersClinical Ethicist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL53653162873AOtherSTATE DRIVERS LICENCE