Healthcare Provider Details

I. General information

NPI: 1356266993
Provider Name (Legal Business Name): BRADYN MICHAEL EUGENE SHAW RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

10628 W CAMAS ST
BOISE ID
83709-1232
US

V. Phone/Fax

Practice location:
  • Phone: 402-641-8009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9881316
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: