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General NPI Number Information
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NPI Number | 1366519563
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Entity Type | Individual
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Provider Name | TABITHA MARIE SHAW MD
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Gender | Female
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Dates
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Enumeration Date | 11/30/2006
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Last Update Date | 02/24/2015
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Provider Practice Location Address
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Address Line | 8195 HIGHWAY 789
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City | LANDER
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State | WY
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Zip | 82520-2942
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Country | US
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Telephone | 307-332-0206
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Fax | 307-332-0479
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Provider Business Mailing Address
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Address Line | 100 N FORK RD
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City | LANDER
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State | WY
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Zip | 82520-9700
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Country | US
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Telephone | 307-332-0206
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Fax | 307-332-0479
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 6232A
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License Number State | WY
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