Basic Information
Provider Information | |||||||||
NPI: | 1336596162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAW | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | KIRK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 966 N GARDEN RIDGE BLVD STE 530 | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750772876 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724206605 | ||||||||
FaxNumber: | 8449659627 | ||||||||
Practice Location | |||||||||
Address1: | 2309 VIRGINIA PKWY # 400 | ||||||||
Address2: |   | ||||||||
City: | MCKINNEY | ||||||||
State: | TX | ||||||||
PostalCode: | 750713505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9725427360 | ||||||||
FaxNumber: | 9725427363 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2016 | ||||||||
LastUpdateDate: | 05/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1275418 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.