Provider Demographics
NPI:1912642802
Name:SHAW, JAQUAN
Entity Type:Individual
Prefix:
First Name:JAQUAN
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 OLD OAK DR APT 201
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4267
Mailing Address - Country:US
Mailing Address - Phone:757-381-4456
Mailing Address - Fax:
Practice Address - Street 1:426 OLD OAK DR APT 201
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4267
Practice Address - Country:US
Practice Address - Phone:757-381-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver