Basic Information
| Provider Information | |||||||||
| NPI: | 1497792667 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3959 BROADWAY | ||||||||
| Address2: | COLUMBIA UNVERSITY DEPARTMENT PEDIATRIC | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100321559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | 2125441974 | ||||||||
| Practice Location | |||||||||
| Address1: | 3959 BROADWAY | ||||||||
| Address2: | COLUMBIA UNVERSITY DEPARTMENT PEDIATRIC | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100321559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123047250 | ||||||||
| FaxNumber: | 2125441974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | F3810081 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02752129 | 05 | NY | MEDICAID | 0105678 | 05 | NJ | MEDICAID |