Provider Demographics
NPI:1972328284
Name:SHAW, ANDREW DENNISON (PRS)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:DENNISON
Last Name:SHAW
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 BROWNELL RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-3406
Mailing Address - Country:US
Mailing Address - Phone:937-576-6501
Mailing Address - Fax:
Practice Address - Street 1:2960 W ENON RD
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-8548
Practice Address - Country:US
Practice Address - Phone:937-272-4925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005744175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist