Provider Demographics
NPI:1780214718
Name:SHAW, SUMAN GOWDA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SUMAN
Middle Name:GOWDA
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:SUMAN
Other - Middle Name:J
Other - Last Name:GOWDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10930 CORTLAND LN
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-4075
Mailing Address - Country:US
Mailing Address - Phone:224-678-2181
Mailing Address - Fax:
Practice Address - Street 1:907 N ELM ST STE 101
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3644
Practice Address - Country:US
Practice Address - Phone:708-482-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020361363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily