Provider Demographics
NPI:1669631545
Name:SHAW, ALNISSA CARTER (PA-C)
Entity Type:Individual
Prefix:DR
First Name:ALNISSA
Middle Name:CARTER
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41008
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-1008
Mailing Address - Country:US
Mailing Address - Phone:800-849-5609
Mailing Address - Fax:910-483-3959
Practice Address - Street 1:811 US HIGHWAY 70 W
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-2541
Practice Address - Country:US
Practice Address - Phone:919-779-5079
Practice Address - Fax:919-779-9268
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC001000089363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MC1582469OtherDEA