Provider Demographics
NPI:1629834452
Name:SHAW-WILGOSKI, SAMUEL (PMHNP)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SHAW-WILGOSKI
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LITTLE POND RD
Mailing Address - Street 2:
Mailing Address - City:MERRIMAC
Mailing Address - State:MA
Mailing Address - Zip Code:01860-2256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 LITTLE POND RD
Practice Address - Street 2:
Practice Address - City:MERRIMAC
Practice Address - State:MA
Practice Address - Zip Code:01860-2256
Practice Address - Country:US
Practice Address - Phone:860-335-2418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2324798163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health