Provider Demographics
NPI:1366488926
Name:SHAW, TRENT E (PA-C)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:E
Last Name:SHAW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1926
Mailing Address - Country:US
Mailing Address - Phone:208-359-1770
Mailing Address - Fax:208-359-1780
Practice Address - Street 1:72 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1926
Practice Address - Country:US
Practice Address - Phone:208-359-1770
Practice Address - Fax:208-359-1780
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-308363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806887500Medicaid
ID1666957Medicare ID - Type Unspecified
IDP20734Medicare UPIN