Provider Demographics
NPI:1336865146
Name:SHAW, DERRICK CHASE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:CHASE
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 CORDOVA DR
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-4538
Mailing Address - Country:US
Mailing Address - Phone:402-705-3896
Mailing Address - Fax:
Practice Address - Street 1:1185 CORDOVA DR
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-4538
Practice Address - Country:US
Practice Address - Phone:402-705-3896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians