Provider Demographics
NPI:1952116501
Name:SHAW, RYAN PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:SHAW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 NE 69TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33138-5763
Mailing Address - Country:US
Mailing Address - Phone:347-549-1180
Mailing Address - Fax:
Practice Address - Street 1:770 NE 69TH ST APT 3A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33138-5763
Practice Address - Country:US
Practice Address - Phone:347-549-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant