Provider Demographics
NPI:1669199642
Name:SHAW, TYANA
Entity type:Individual
Prefix:
First Name:TYANA
Middle Name:
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 1:4965 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-7757
Mailing Address - Country:US
Mailing Address - Phone:510-703-2130
Mailing Address - Fax:
Practice Address - Street 1:4965 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-7757
Practice Address - Country:US
Practice Address - Phone:510-703-2130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RI0001207RI0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology