Provider Demographics
NPI:1053917823
Name:SHAW, FORREST CRANE
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:CRANE
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 W WHITNEY ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4719
Mailing Address - Country:US
Mailing Address - Phone:307-763-6062
Mailing Address - Fax:
Practice Address - Street 1:407 W LOUCKS ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4128
Practice Address - Country:US
Practice Address - Phone:307-763-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator