Provider Demographics
NPI:1962931287
Name:SHAW, NATHAN LEVI (PMHNP)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:LEVI
Last Name:SHAW
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5311
Mailing Address - Country:US
Mailing Address - Phone:480-993-4674
Mailing Address - Fax:
Practice Address - Street 1:2500 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7994
Practice Address - Country:US
Practice Address - Phone:928-537-2951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP102032084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry