Provider Demographics
NPI:1407179690
Name:SHAW, CHRISTOPHER JOEL (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOEL
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 1:13236 NE 129TH PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3361
Mailing Address - Country:US
Mailing Address - Phone:425-814-5100
Mailing Address - Fax:425-814-5103
Practice Address - Street 1:11800 NE 128TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-814-5100
Practice Address - Fax:425-814-5103
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60124508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00946049OtherRAILROAD MEDICARE
WA0260915OtherL AND I
WA1407179690Medicaid
WA0260915OtherL AND I
WAP00946049OtherRAILROAD MEDICARE