Provider Demographics
NPI:1003967217
Name:SHAW, MARTHA JEAN
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:JEAN
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 COUNTY ROAD 343
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MS
Mailing Address - Zip Code:38673-4541
Mailing Address - Country:US
Mailing Address - Phone:662-236-4543
Mailing Address - Fax:
Practice Address - Street 1:188 COUNTY ROAD 343
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MS
Practice Address - Zip Code:38673-4541
Practice Address - Country:US
Practice Address - Phone:662-236-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS164W00000X164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770204Medicaid