Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0131X | Foot Surgery | 80199 | MS |
NPI | 1376783324 |
---|---|
Provider Name | Dr. Renita Ta'sha Shaw |
First Address | Wiggins, MS 39503 |
Second Address | Wiggins, MS 39577-9602 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/03/2009 |
Last Update Date | 15/06/2012 |