Provider Demographics
NPI:1689716466
Name:SHAW, LAWRENCE GLEN (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:GLEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 W CHARLESTON BLVD
Mailing Address - Street 2:#215
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-968-4347
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-5140
Practice Address - Fax:702-385-2745
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV12185207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDG109ZMedicare PIN
NVDG109YMedicare PIN