Provider Demographics
NPI:1902394646
Name:SHAW, ASHLEY ERICKSEN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:ERICKSEN
Last Name:SHAW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 SUNCREST DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1997
Mailing Address - Country:US
Mailing Address - Phone:843-601-0351
Mailing Address - Fax:
Practice Address - Street 1:9820 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4013
Practice Address - Country:US
Practice Address - Phone:843-497-2273
Practice Address - Fax:843-497-2502
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21809363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
9311OtherCIGNA
SCGP5525Medicaid
9311OtherBLUE CHOICE
SC9311OtherMEDICARE
93199OtherHUMANA
93199OtherAETNA
9311OtherBLUE CROSS BLUE SHIELD
9311OtherFIRST CHOICE BY SELECT HEALTH OF SOUTH CAROLINA