Basic Information
Provider Information | |||||||||
NPI: | 1063836609 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAW | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | ANTWAIN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MAE | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PAWNEE COUNTY 907 W. CADDO ST. | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OK | ||||||||
PostalCode: | 740204201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183085511 | ||||||||
FaxNumber: | 9182052701 | ||||||||
Practice Location | |||||||||
Address1: | 907 W CADDO ST | ||||||||
Address2: |   | ||||||||
City: | CLEVELAND | ||||||||
State: | OK | ||||||||
PostalCode: | 740204201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9183085511 | ||||||||
FaxNumber: | 9182052701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/18/2014 | ||||||||
LastUpdateDate: | 03/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   | OK | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.