Healthcare Provider Details

I. General information

NPI: 1427127588
Provider Name (Legal Business Name): AMY ELIZABETH SHAW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOTOYOME STREET
SANTA ROSA CA
95405-4823
US

IV. Provider business mailing address

121 SOTOYOME STREET
SANTA ROSA CA
95405-4823
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-4062
  • Fax: 707-525-8067
Mailing address:
  • Phone: 707-546-4062
  • Fax: 707-525-8067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG69999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: