Provider Demographics
NPI:1912215906
Name:SHAW, PHILLIP ALLEN (MED, ATC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ALLEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 OAK TRL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-9672
Mailing Address - Country:US
Mailing Address - Phone:318-381-0140
Mailing Address - Fax:
Practice Address - Street 1:681 HIGHWAY 594
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8900
Practice Address - Country:US
Practice Address - Phone:318-381-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAJ001502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer