Provider Demographics
NPI:1942738323
Name:SHAW, DARRELL LEVERN (CST/CSFA)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:LEVERN
Last Name:SHAW
Suffix:
Gender:M
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8116 ARLINGTON BLVD STE 183
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1002
Mailing Address - Country:US
Mailing Address - Phone:703-659-4557
Mailing Address - Fax:703-205-9010
Practice Address - Street 1:8116 ARLINGTON BLVD STE 183
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1002
Practice Address - Country:US
Practice Address - Phone:703-659-4557
Practice Address - Fax:703-205-9010
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSA0189246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
170342OtherNBSTSA
DCSA0189OtherDEPT OF HEALTH BOARD OF MEDICINE