Provider Demographics
NPI:1770639635
Name:SHAW, ANNETTA M (RN,BSN,CRNFA)
Entity Type:Individual
Prefix:
First Name:ANNETTA
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:RN,BSN,CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 GREENLEAF AVE NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5817
Mailing Address - Country:US
Mailing Address - Phone:218-751-9746
Mailing Address - Fax:218-759-0620
Practice Address - Street 1:3807 GREENLEAF AVE NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5817
Practice Address - Country:US
Practice Address - Phone:218-751-9746
Practice Address - Fax:218-759-0620
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85G67SHOtherBLUE CROSS BLUE SHIELD
MN855911029535OtherPREFFEREDONE