Healthcare Provider Details

I. General information

NPI: 1679431209
Provider Name (Legal Business Name): TYRA SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 01/13/2026
Certification Date: 01/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 5T ST NE APT 401
DEVILS LAKE ND
58301
US

IV. Provider business mailing address

418 5T ST NE APT 401
DEVILS LAKE ND
58301
US

V. Phone/Fax

Practice location:
  • Phone: 701-381-0868
  • Fax:
Mailing address:
  • Phone: 701-381-0868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: