Provider Demographics
NPI:1841242641
Name:SHAW, MARIAN E (MD)
Entity Type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:E
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-489-4063
Practice Address - Street 1:600 N ROBBINS RD
Practice Address - Street 2:SUITE 301
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-489-4900
Practice Address - Fax:208-489-4063
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5056207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000367000Medicaid
ID1841242641Medicaid
ID20005624Medicare PIN