Provider Demographics
NPI:1790077691
Name:SHAW, TORIA M (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TORIA
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1216
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1216
Mailing Address - Country:US
Mailing Address - Phone:662-624-4292
Mailing Address - Fax:
Practice Address - Street 1:1820 PEABODY ST
Practice Address - Street 2:
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676-9441
Practice Address - Country:US
Practice Address - Phone:662-363-3656
Practice Address - Fax:662-363-3789
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR873829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR873829OtherRN NUMBER