Provider Demographics
NPI:1689221459
Name:SHAW, CHANDRA ANGELICA
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:ANGELICA
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S STATE COLLEGE BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5814
Mailing Address - Country:US
Mailing Address - Phone:888-777-1945
Mailing Address - Fax:805-413-9099
Practice Address - Street 1:9351 GRANT ST STE 110
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4364
Practice Address - Country:US
Practice Address - Phone:887-777-1945
Practice Address - Fax:805-413-9099
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61527785363L00000X
CA95025482363L00000X
COAPN.0994932-NP363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care