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NPI Code Detail

MEDICARE: JESSAMYN SHAW PTA,

MEDICARE: JESSAMYN SHAW PTA,
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
1225200000XPhysical Therapy AssistantAT 8021CA
2225200000XPhysical Therapy AssistantA-0669NV

General Provider Information

NPI Number : 1811100241
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSAMYN SHAW PTA,
Provider Business Mailing Address
First Line : 6717 CHAMBERS LAKE CT
Second Line :
City : NORTH LAS VEGAS
State : NV
Zip : 89084-2384
Country : US
Telephone Number : 760-409-9684
Fax Number :
Provider Business Practice Location Address
First Line : 2250 E FLAMINGO RD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-5170
Country : US
Telephone Number : 702-784-4303
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/08/2007
Last Update Date : 04/16/2015

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