Provider Demographics
NPI:1649260654
Name:SHAW, DANIEL D (PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:SHAW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 W GEORGIA AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6811
Mailing Address - Country:US
Mailing Address - Phone:208-463-3291
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:290 W GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2835
Practice Address - Country:US
Practice Address - Phone:208-468-5970
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149920OtherBLUE SHIELD
IDTC233OtherBLUE CROSS
IDP00217946OtherRAILROAD MEDICARE
ID807145100Medicaid
IDTC233OtherBLUE CROSS
IDP00217946OtherRAILROAD MEDICARE