Provider Demographics
NPI:1609049212
Name:SHAW, RYAN C (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:SHAW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 KEMPSVILLE RD STE 212
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3920
Mailing Address - Country:US
Mailing Address - Phone:757-261-5977
Mailing Address - Fax:
Practice Address - Street 1:850 KEMPSVILLE RD STE 212
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3920
Practice Address - Country:US
Practice Address - Phone:757-261-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant