Organization Name: | SHAW FAMILY MEDICAL, LLC |
NPI Number: | 1043665532 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | NORA GOUGH-DAVIS (OWNER) |
Mailing Address: | 189 N Main St Drew |
State: | MS US |
Postal Code: | 387373146 |
Phone Number: | 6627456638 |
Fax Number: | 6627458480 |
NPI Enumeration Date: | 05/03/2016 |
NPI Last Update Date: | 05/03/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | R872155 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MS |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |