Basic Information
| Provider Information | |||||||||
| NPI: | 1538308986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6730 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852466730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808213600 | ||||||||
| FaxNumber: | 4808213610 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 S VAL VISTA DR | ||||||||
| Address2: | STE 203 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808213616 | ||||||||
| FaxNumber: | 4808572667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2009 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MT185784 | PA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | 42127 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | FC0592596 | 01 | AZ | DEA CERTFICATION | OTHER | 435318 | 05 | AZ | MEDICAID |