Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 202108944NP-PP | OR |
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 47689 | WY |
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 836571 | NV |
N | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 95017588 | CA |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | AP61160807 | WA |
NPI | 1023641743 |
---|---|
Provider Name | Jonathan Shaw |
First Address | Sheridan, WY 82801-5777 |
Second Address | Glendale, CA 91206-4007 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/02/2020 |
Last Update Date | 25/01/2022 |