Basic Information
| Provider Information | |||||||||
| NPI: | 1205114816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | CHRISTIAN | ||||||||
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| Credential: | M.D., PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3219 EAST CAMELBACK ROAD | ||||||||
| Address2: | STE 297 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024039167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 912 1ST ST NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052249777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2011 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | MD20130858 | NM | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 2083A0300X | MD20130858 | NM | Y |
ID Information
| ID | Type | State | Issuer | Description | 12653055 | 05 | NM | MEDICAID |