Provider Demographics
NPI:1942798962
Name:SHAW, ANGELICA PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:PATRICIA
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:PATRICIA
Other - Last Name:BOLIVAR GUERRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 639970
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7001 FOREST AVE STE 405
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1726
Practice Address - Country:US
Practice Address - Phone:804-285-6811
Practice Address - Fax:804-281-7264
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2021-0878208000000X
TX681703208000000X
VA0101281387208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93232888Medicaid