Healthcare Provider Details

I. General information

NPI: 1821980566
Provider Name (Legal Business Name): LOREL MARIE SHAW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 CARPENTER ST
PROVIDENCE RI
02903-3044
US

IV. Provider business mailing address

219 CARPENTER ST # 1R
PROVIDENCE RI
02903-3044
US

V. Phone/Fax

Practice location:
  • Phone: 401-000-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01825
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: