Basic Information
| Provider Information | |||||||||
| NPI: | 1962969931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAGSHAW | ||||||||
| FirstName: | SHAYNA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 556 5TH AVE APT 2 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941183947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208707880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 BON AIR RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154481500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2019 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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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 | 133V00000X | 86063915 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 86063915 | 01 | CA | COMMISSION ON DIETETIC REGISTRATION | OTHER |