Provider Demographics
NPI:1871532101
Name:SHAW, DANA M (APRN)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 HOLLADAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5206
Mailing Address - Country:US
Mailing Address - Phone:801-277-2682
Mailing Address - Fax:801-277-2980
Practice Address - Street 1:4624 HOLLADAY BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5206
Practice Address - Country:US
Practice Address - Phone:801-277-2682
Practice Address - Fax:801-277-2980
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT224930-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ03122Medicare UPIN