Provider Demographics
NPI:1124092002
Name:SHAW, TIMOTHY L (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:SHAW
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11055 OWHAT CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8226
Mailing Address - Country:US
Mailing Address - Phone:907-227-9592
Mailing Address - Fax:
Practice Address - Street 1:11055 OWHAT CIR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8226
Practice Address - Country:US
Practice Address - Phone:907-227-9592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK26580367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered