Healthcare Provider Details

I. General information

NPI: 1104649375
Provider Name (Legal Business Name): HEIDI SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 KENDALL RD
SAN LUIS OBISPO CA
93401-8750
US

IV. Provider business mailing address

1255 KENDALL RD
SAN LUIS OBISPO CA
93401-8750
US

V. Phone/Fax

Practice location:
  • Phone: 805-704-6252
  • Fax:
Mailing address:
  • Phone: 805-704-6252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: