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General NPI Number Information
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NPI Number | 1659948321
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Entity Type | Individual
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Provider Name | TRACIE SHAW DPM
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Gender | Female
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Dates
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Enumeration Date | 06/09/2021
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Last Update Date | 08/13/2024
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Provider Practice Location Address
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Address Line | 5365 WALNUT AVE STE P
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City | CHINO
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State | CA
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Zip | 91710-2622
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Country | US
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Telephone | 909-946-6643
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Fax |
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Provider Business Mailing Address
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Address Line | 1039 S INDIAN SUMMER AVE
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City | WEST COVINA
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State | CA
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Zip | 91790-5216
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Country | US
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Telephone | 626-660-5239
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | E5975
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License Number State | CA
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