Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 109774 | MO |
NPI | 1912940958 |
---|---|
Provider Name | Gary Y. Shaw |
First Address | Canton, IL 61520-2608 |
Second Address | Canton, IL 61520-2608 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 13/04/2021 |