Provider Demographics
NPI:1912293572
Name:SHAW, JESSE DANIEL (DO)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:DANIEL
Last Name:SHAW
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 SE BISHOP BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5517
Mailing Address - Country:US
Mailing Address - Phone:509-332-2828
Mailing Address - Fax:509-334-7474
Practice Address - Street 1:825 SE BISHOP BLVD STE 120
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5517
Practice Address - Country:US
Practice Address - Phone:509-332-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1908207QS0010X
WAOP61106819207QS0010X
VA0102203194202C00000X
AL1848207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner