Provider Demographics
NPI:1477170546
Name:SHAW, KANWON (PA-C)
Entity Type:Individual
Prefix:
First Name:KANWON
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
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 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-5500
Mailing Address - Fax:
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-6106
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA9338207R00000X
363A00000X
MAPA9339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine