Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | DD1563 | NM |
NPI | 1134334907 |
---|---|
Provider Name | Dr. Colin Simeon Shaw |
First Address | Albuquerque, NM 87109-2120 |
Second Address | Albuquerque, NM 87109-2120 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2007 |
Last Update Date | 08/07/2007 |