Provider Demographics
NPI:1083586309
Name:SHAW, KRISTA L (CCADC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:CCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FOREST OAKS DR
Mailing Address - Street 2:
Mailing Address - City:IRON STATION
Mailing Address - State:NC
Mailing Address - Zip Code:28080-9613
Mailing Address - Country:US
Mailing Address - Phone:918-289-0270
Mailing Address - Fax:
Practice Address - Street 1:4949A ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6617
Practice Address - Country:US
Practice Address - Phone:918-289-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-293932083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine