Provider Demographics
NPI:1700865904
Name:SHAW, KIMBERLY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
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 1:11532 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE GRASS
Mailing Address - State:IA
Mailing Address - Zip Code:52726-9660
Mailing Address - Country:US
Mailing Address - Phone:563-381-5041
Mailing Address - Fax:
Practice Address - Street 1:200 CODY RD S
Practice Address - Street 2:
Practice Address - City:LE CLAIRE
Practice Address - State:IA
Practice Address - Zip Code:52753-9579
Practice Address - Country:US
Practice Address - Phone:563-289-2273
Practice Address - Fax:563-289-1605
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001653363AM0700X
GA005650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP60008Medicare UPIN
IAI16141Medicare ID - Type Unspecified