Provider Demographics
NPI:1679541098
Name:TYWON, SHAWN E (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:E
Last Name:TYWON
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 1:420 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1802
Mailing Address - Country:US
Mailing Address - Phone:229-375-2522
Mailing Address - Fax:229-329-4140
Practice Address - Street 1:420 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-375-2522
Practice Address - Fax:229-329-4140
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2613363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290780100Medicaid
GA100001467AMedicaid
GA100001467AMedicaid
S27458Medicare UPIN
FL290780100Medicaid