=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083586309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA L SHAW CCADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2025
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4949A ALBEMARLE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28205-6617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-289-0270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 FOREST OAKS DR
-----------------------------------------------------
City | IRON STATION
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28080-9613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-289-0270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083A0300X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number | CADC-29393
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------