Provider Demographics
NPI:1871566695
Name:SHAW, GARRET T (MD)
Entity type:Individual
Prefix:
First Name:GARRET
Middle Name:T
Last Name:SHAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 20TH ST
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-1237
Mailing Address - Country:US
Mailing Address - Phone:308-537-4066
Mailing Address - Fax:308-537-3074
Practice Address - Street 1:918 20TH ST
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1237
Practice Address - Country:US
Practice Address - Phone:308-537-4066
Practice Address - Fax:308-537-3074
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025024000OtherMEDICAID RHC
NE470426208Medicaid
NE10025024000OtherMEDICAID RHC
273799Medicare ID - Type Unspecified