Healthcare Provider Details

I. General information

NPI: 1871280347
Provider Name (Legal Business Name): SAMANTHA J SHAW FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 01/10/2026
Certification Date: 01/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OCEANGATE STE 100
LONG BEACH CA
90802-4317
US

IV. Provider business mailing address

457B HIGHWAY 123
SENECA SC
29678-0842
US

V. Phone/Fax

Practice location:
  • Phone: 864-466-2656
  • Fax:
Mailing address:
  • Phone: 864-888-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27295
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14256449-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1218783
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: