Provider Demographics
NPI:1467837716
Name:SHAW, ANDREW W (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
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 1:341 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3330
Mailing Address - Country:US
Mailing Address - Phone:951-735-6060
Mailing Address - Fax:
Practice Address - Street 1:341 MAGNOLIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3330
Practice Address - Country:US
Practice Address - Phone:951-735-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60605829363A00000X, 363AS0400X
CAPA53882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical