Provider Demographics
NPI:1679642037
Name:SHAW, BRENDA J (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
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 1:1660 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4360
Mailing Address - Country:US
Mailing Address - Phone:208-523-8844
Mailing Address - Fax:208-529-8684
Practice Address - Street 1:1660 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4360
Practice Address - Country:US
Practice Address - Phone:208-523-8844
Practice Address - Fax:208-529-8684
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807324700Medicaid
ID1667325Medicare PIN
Q58778Medicare UPIN