Provider Demographics
NPI:1932302759
Name:SHAW, MICHELLE ROSEANN (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSEANN
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28122
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-8122
Mailing Address - Country:US
Mailing Address - Phone:503-449-3964
Mailing Address - Fax:
Practice Address - Street 1:1500 DIVISION ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1527
Practice Address - Country:US
Practice Address - Phone:503-449-3964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD152189207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services