Provider Demographics
NPI:1699058628
Name:SHAW, WILLIAM BRADLEY (DC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADLEY
Last Name:SHAW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 E 500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3312
Mailing Address - Country:US
Mailing Address - Phone:801-530-4802
Mailing Address - Fax:
Practice Address - Street 1:479 E 500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3312
Practice Address - Country:US
Practice Address - Phone:801-530-4802
Practice Address - Fax:801-530-0146
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8054945-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor