Basic Information
| Provider Information | |||||||||
| NPI: | 1578684809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANG | ||||||||
| FirstName: | SHAW | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 S JACKSON AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186318130 | ||||||||
| FaxNumber: | 9186318134 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 S JACKSON AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186318130 | ||||||||
| FaxNumber: | 9186318134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 6508 | OK | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200785150A | 05 | OK | MEDICAID | 691847 | 01 | OK | MEDICARE | OTHER |