Provider Demographics
NPI:1770798928
Name:SHAW, AMY LORANCE (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LORANCE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:LORANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6601 N SHAWNEE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1801
Mailing Address - Country:US
Mailing Address - Phone:405-463-3357
Mailing Address - Fax:
Practice Address - Street 1:6400 N SANTA FE AVE
Practice Address - Street 2:STE B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-9126
Practice Address - Country:US
Practice Address - Phone:405-840-2903
Practice Address - Fax:405-840-3256
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant