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NPI Code Detail

MEDICARE: DR. NICOLE JOHNISE SHAW MD

MEDICARE: DR. NICOLE JOHNISE SHAW MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianA204378CA

General Provider Information

NPI Number : 1780315473
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. NICOLE JOHNISE SHAW MD
Provider Business Mailing Address
First Line : 4476 TWEEDY BLVD STE B
Second Line :
City : SOUTH GATE
State : CA
Zip : 90280-6359
Country : US
Telephone Number : 323-825-8300
Fax Number : 866-372-2719
Provider Business Practice Location Address
First Line : 4476 TWEEDY BLVD STE B
Second Line :
City : SOUTH GATE
State : CA
Zip : 90280-6359
Country : US
Telephone Number : 323-825-8300
Fax Number : 866-372-2719
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/22/2022
Last Update Date : 03/18/2026

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Directions to “ DR. NICOLE JOHNISE SHAW MD” Practice Location

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