Basic Information
Provider Information
NPI: 1316967656
EntityType: 2
ReplacementNPI:  
OrganizationName: SHAW P WAN UROLOGY PLLC
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Mailing Information
Address1: 1009 NORTH 6TH STREET
Address2:  
City: ALBEMARLE
State: NC
PostalCode: 28001
CountryCode: US
TelephoneNumber: 7049822800
FaxNumber: 7049822830
Practice Location
Address1: 1009 NORTH 6TH STREET
Address2:  
City: ALBEMARLE
State: NC
PostalCode: 28001
CountryCode: US
TelephoneNumber: 7049822800
FaxNumber: 7049822830
Other Information
ProviderEnumerationDate: 07/20/2006
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: WAN
AuthorizedOfficialFirstName: SHAW
AuthorizedOfficialMiddleName: P
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 7049822800
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208800000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansUrology 

ID Information
IDTypeStateIssuerDescription
590307305NC MEDICAID


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