Provider Demographics
NPI:1770185225
Name:SHAW, STACY SHANE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:SHANE
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3814 SE 98TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2502
Mailing Address - Country:US
Mailing Address - Phone:503-313-9634
Mailing Address - Fax:
Practice Address - Street 1:725 NORTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4109
Practice Address - Country:US
Practice Address - Phone:413-447-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical