Provider Demographics
NPI:1164501565
Name:SHAW, MELISSA M (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:SHAW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 671904
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-1904
Mailing Address - Country:US
Mailing Address - Phone:907-545-0137
Mailing Address - Fax:907-688-0367
Practice Address - Street 1:22245 ANTHEM PL
Practice Address - Street 2:
Practice Address - City:CHIGIAK
Practice Address - State:AK
Practice Address - Zip Code:99567-7020
Practice Address - Country:US
Practice Address - Phone:907-545-0137
Practice Address - Fax:907-688-0367
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid
AK1020986Medicaid