Provider Demographics
NPI:1659948321
Name:SHAW, TRACIE (DPM)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6145 AVON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-2605
Mailing Address - Country:US
Mailing Address - Phone:626-660-5239
Mailing Address - Fax:
Practice Address - Street 1:5451 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2609
Practice Address - Country:US
Practice Address - Phone:909-706-3877
Practice Address - Fax:909-706-3942
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAEL7024213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program