Provider Demographics
NPI:1578796439
Name:LIES, SHAWN CHARLES (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:CHARLES
Last Name:LIES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PORTER DR
Mailing Address - Street 2:215
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1587
Mailing Address - Country:US
Mailing Address - Phone:925-362-2166
Mailing Address - Fax:855-574-3055
Practice Address - Street 1:3315 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5717
Practice Address - Country:US
Practice Address - Phone:510-486-2300
Practice Address - Fax:510-486-2333
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52420363AS0400X
363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA178510Medicare PIN