Basic Information
| Provider Information | |||||||||
| NPI: | 1669092060 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 696 MOWBRAY ARCH APT 720 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172903706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5544 GREENWICH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2020 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110007357 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.