Provider Demographics
NPI:1538290614
Name:SHAW, COLLEEN (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-1115
Mailing Address - Country:US
Mailing Address - Phone:518-736-1911
Mailing Address - Fax:518-736-1923
Practice Address - Street 1:400 N PERRY ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-1115
Practice Address - Country:US
Practice Address - Phone:518-736-1911
Practice Address - Fax:518-736-1923
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0852001PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY346851OtherMVP HEALTHPLAN
NY0852001PAOtherLISCENSE
NY000414322001OtherBLUE SHIELD
NY00473643Medicaid