Provider Demographics
NPI:1720360746
Name:SHAW, LESLIE S (NP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:S
Last Name:SHAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LUCILLE LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1031
Mailing Address - Country:US
Mailing Address - Phone:856-874-1159
Mailing Address - Fax:
Practice Address - Street 1:360 ROUTE 73 S
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2004
Practice Address - Country:US
Practice Address - Phone:856-596-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00345100363LF0000X
PASP016443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily