Provider Demographics
NPI:1700845013
Name:SHAW BARBACCIA, DOROTHY M (CRNA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:M
Last Name:SHAW BARBACCIA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W COMMERCIAL BLVD # 4-5
Mailing Address - Street 2:C/O ANESCO NORTH BROWARD LLC
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3300
Mailing Address - Country:US
Mailing Address - Phone:954-485-5666
Mailing Address - Fax:954-484-1651
Practice Address - Street 1:2351 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-6759
Practice Address - Country:US
Practice Address - Phone:561-732-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1812502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301182800Medicaid
FLG0717YMedicare ID - Type Unspecified
FL301182800Medicaid