Healthcare Provider Details

I. General information

NPI: 1750885901
Provider Name (Legal Business Name): ASHLEY M SHAW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 E RIVER BLUFF BLVD
OZARK MO
65721-8807
US

IV. Provider business mailing address

3050 E RIVER BLUFF BLVD
OZARK MO
65721-8807
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-5610
  • Fax:
Mailing address:
  • Phone: 417-820-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2018009775
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: