Provider Demographics
NPI:1962432757
Name:SHAW, PATTI WANNETTA (DO)
Entity type:Individual
Prefix:DR
First Name:PATTI
Middle Name:WANNETTA
Last Name:SHAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:9228 S MINGO RD
Mailing Address - Street 2:STE 103
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5718
Mailing Address - Country:US
Mailing Address - Phone:918-392-7575
Mailing Address - Fax:918-615-3465
Practice Address - Street 1:9228 S. MINGO
Practice Address - Street 2:SUITE 103
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5721
Practice Address - Country:US
Practice Address - Phone:918-392-7575
Practice Address - Fax:918-615-3465
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-05-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK3601207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100132300AMedicaid
OK100132300AMedicaid
H24201Medicare UPIN