Provider Demographics
NPI:1316450125
Name:SHAW, WILLIAM ALTON (FNP-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALTON
Last Name:SHAW
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WESSON
Mailing Address - State:MS
Mailing Address - Zip Code:39191-8914
Mailing Address - Country:US
Mailing Address - Phone:601-643-5808
Mailing Address - Fax:601-643-5808
Practice Address - Street 1:213 CALDWELL DR
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2711
Practice Address - Country:US
Practice Address - Phone:601-894-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily