Provider Demographics
NPI:1689981623
Name:SHAW, ALAN BLAKE (LAC)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:BLAKE
Last Name:SHAW
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2507
Mailing Address - Country:US
Mailing Address - Phone:208-284-0313
Mailing Address - Fax:
Practice Address - Street 1:1412 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2507
Practice Address - Country:US
Practice Address - Phone:208-284-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-212171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist