Provider Demographics
NPI:1780315473
Name:SHAW, NICOLE JOHNISE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JOHNISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CITY AVE
Mailing Address - Street 2:MADISON BUILDING APARTMENT 211
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131
Mailing Address - Country:US
Mailing Address - Phone:510-457-5267
Mailing Address - Fax:
Practice Address - Street 1:8835 GERMANTOWN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2718
Practice Address - Country:US
Practice Address - Phone:215-482-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT227223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine