Provider Demographics
NPI:1053029801
Name:SHAW, CLAUDE GOODMAN JR (PTA)
Entity type:Individual
Prefix:
First Name:CLAUDE
Middle Name:GOODMAN
Last Name:SHAW
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6624 BROOKMEADE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-7724
Mailing Address - Country:US
Mailing Address - Phone:980-254-3560
Mailing Address - Fax:
Practice Address - Street 1:5800 OLD PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-6872
Practice Address - Country:US
Practice Address - Phone:704-365-8551
Practice Address - Fax:704-365-8505
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA2534225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant