Provider Demographics
NPI:1134258163
Name:SHAW, WILLIAM J IV (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:SHAW
Suffix:IV
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 ACME BRICK PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4124
Mailing Address - Country:US
Mailing Address - Phone:817-529-1900
Mailing Address - Fax:817-529-1910
Practice Address - Street 1:2901 ACME BRICK PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4124
Practice Address - Country:US
Practice Address - Phone:817-529-1900
Practice Address - Fax:817-529-1910
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04686363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1467497735OtherGROUP NPI
TX00W771Medicare PIN
1467497735OtherGROUP NPI