Provider Demographics
NPI:1306943071
Name:SHAW, MATTIE (LMP)
Entity type:Individual
Prefix:MS
First Name:MATTIE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 STONE WAY N
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8000
Mailing Address - Country:US
Mailing Address - Phone:206-992-2482
Mailing Address - Fax:
Practice Address - Street 1:4110 STONE WAY N
Practice Address - Street 2:SUITE 201
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8000
Practice Address - Country:US
Practice Address - Phone:206-992-2482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00003216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist