Provider Demographics
NPI:1225518509
Name:SHAW, KYLEE (PA)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA
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Other - Middle Name:
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Mailing Address - Street 1:147 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2314
Mailing Address - Country:US
Mailing Address - Phone:208-238-7546
Mailing Address - Fax:208-237-9643
Practice Address - Street 1:1411 FALLS AVE E STE 1002
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3459
Practice Address - Country:US
Practice Address - Phone:208-595-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2023-08-10
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical