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General NPI Number Information
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NPI Number | 1366254708
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Entity Type | Individual
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Provider Name | DALTON S SHAW
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Gender | Male
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Dates
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Enumeration Date | 01/23/2025
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Last Update Date | 01/28/2025
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Provider Practice Location Address
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Address Line | 100 PAR LN
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-9023
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Country | US
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Telephone | 270-312-2500
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Fax |
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Provider Business Mailing Address
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Address Line | 211 PONDEROSA DR
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2668
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Country | US
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Telephone | 270-801-3237
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 1202722
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License Number State | KY
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