Provider Demographics
NPI:1437444163
Name:SHAW, EVERETT LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:EVERETT
Middle Name:LEE
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 1:517 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1668
Mailing Address - Country:US
Mailing Address - Phone:618-833-4300
Mailing Address - Fax:618-833-9058
Practice Address - Street 1:4775 E MARYLAND ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-8820
Practice Address - Country:US
Practice Address - Phone:217-864-3737
Practice Address - Fax:217-864-3468
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205790002OtherMEDICARE PTAN
1051123OtherNCCAP NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS