Provider Demographics
NPI:1427408251
Name:MUSGROVE, SHANE (PA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:MUSGROVE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:3399 E LOUISE DR STE 400
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5212
Practice Address - Country:US
Practice Address - Phone:208-706-4650
Practice Address - Fax:208-706-4651
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO4759363A00000X
IDPA-1610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant