Basic Information
| Provider Information | |||||||||
| NPI: | 1982624318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | GILLIAN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 359 W NAHAHUM CANYON RD | ||||||||
| Address2: | |||||||||
| City: | CASHMERE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988159680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096302279 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 TERRACINA BLVD | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923734850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093355500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00026804 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | MD00026804 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 133414 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 48262 | 01 | WA | L&I | OTHER | 8151359 | 05 | WA | MEDICAID |