Healthcare Provider Details

I. General information

NPI: 1265087290
Provider Name (Legal Business Name): DANIEL LAURENCE SHAW AGACNP, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N ROSE AVE
OXNARD CA
93030-3722
US

IV. Provider business mailing address

11856 BALBOA BLVD # 154
GRANADA HILLS CA
91344-2753
US

V. Phone/Fax

Practice location:
  • Phone: 805-988-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95012157
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: