Provider Demographics
NPI:1942721592
Name:SHAW, BRADLEY J (CRNP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:SHAW
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N 2ND ST STE 5
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16830-2547
Mailing Address - Country:US
Mailing Address - Phone:814-205-4025
Mailing Address - Fax:814-240-6632
Practice Address - Street 1:216 N 2ND ST STE 5
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:PA
Practice Address - Zip Code:16830-2547
Practice Address - Country:US
Practice Address - Phone:814-205-4025
Practice Address - Fax:814-240-6632
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022269363LP0808X
PASP017631363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily