Provider Demographics
NPI:1417790338
Name:SHAW, EMILY BETSILL
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:BETSILL
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 LIFSEY SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:GA
Mailing Address - Zip Code:30295-6555
Mailing Address - Country:US
Mailing Address - Phone:678-588-2232
Mailing Address - Fax:
Practice Address - Street 1:502 W MAIN ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-6209
Practice Address - Country:US
Practice Address - Phone:706-938-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN297863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily