Healthcare Provider Details

I. General information

NPI: 1053247213
Provider Name (Legal Business Name): TARA ASHLEY SHAW DNAP, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

107 WHITE OAKS BLVD
PANAMA CITY FL
32409-2371
US

V. Phone/Fax

Practice location:
  • Phone: 850-767-8341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberAPRN11048312
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: