Provider Demographics
NPI:1851467013
Name:SHAW, ROXANA (MPAS, PA-C, CHC)
Entity Type:Individual
Prefix:MS
First Name:ROXANA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MPAS, PA-C, CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 ALBANY POST RD
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-1766
Mailing Address - Country:US
Mailing Address - Phone:845-229-8977
Mailing Address - Fax:845-229-8930
Practice Address - Street 1:3991 MACARTHUR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3048
Practice Address - Country:US
Practice Address - Phone:949-887-7187
Practice Address - Fax:949-553-4136
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005335-1363A00000X
CAPA55445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY524PL1Medicare ID - Type Unspecified