Healthcare Provider Details

I. General information

NPI: 1275791725
Provider Name (Legal Business Name): MARY ELIZABETH SHAW HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 10TH ST SW
MINOT ND
58701-2013
US

IV. Provider business mailing address

2400 10TH ST SW
MINOT ND
58701-2013
US

V. Phone/Fax

Practice location:
  • Phone: 701-852-1897
  • Fax: 701-839-0364
Mailing address:
  • Phone: 701-852-1897
  • Fax: 701-839-0364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHOO87
License Number StateND

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: