Provider Demographics
NPI:1679670780
Name:SHAW, LYNNE B (PA-C)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:B
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 1:164 TIVOLI LN
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4602
Mailing Address - Country:US
Mailing Address - Phone:925-822-6940
Mailing Address - Fax:
Practice Address - Street 1:112 LA CASA VIA STE 360
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3060
Practice Address - Country:US
Practice Address - Phone:925-935-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13689OtherPA LICENSE NUMBER