Healthcare Provider Details

I. General information

NPI: 1770111817
Provider Name (Legal Business Name): BRENDAN BARRETT SHAW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 WHITCHER ST NE STE 4120
MARIETTA GA
30060-1179
US

IV. Provider business mailing address

61 WHITCHER ST NE STE 4120
MARIETTA GA
30060-1179
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-9732
  • Fax: 770-421-0228
Mailing address:
  • Phone: 770-424-9732
  • Fax: 770-421-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10184
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: