Provider Demographics
NPI:1700346194
Name:SHAW, KRISTA (NP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:CALLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:47 HIGH ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845
Mailing Address - Country:US
Mailing Address - Phone:978-685-2460
Mailing Address - Fax:978-685-2472
Practice Address - Street 1:47 HIGH ST.
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845
Practice Address - Country:US
Practice Address - Phone:978-685-2460
Practice Address - Fax:978-685-2472
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2267266363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2267266OtherSTATE LICENSE - MA