Individual
GRACE SHAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
O.D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
1766
AZ
152W00000X
Optometrist
Primary
2836
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
74123777
—
CO
01
—
OPT.0002836
CO OPTOMETRY LICENSE
CO
Enumeration date
09/17/2010
Last updated
06/12/2019
Update your record
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