Provider Demographics
NPI:1881045896
Name:SHAW, NEIL (NP)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2700
Mailing Address - Country:US
Mailing Address - Phone:231-932-4912
Mailing Address - Fax:
Practice Address - Street 1:1200 SIXTH ST STE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-5799
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner