Provider Demographics
NPI:1760923635
Name:ANDREASEN, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:ANDREASEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BYU IDAHO STUDENT HEALTH CENTER 179 CTR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83460-0001
Mailing Address - Country:US
Mailing Address - Phone:208-496-9341
Mailing Address - Fax:208-496-9343
Practice Address - Street 1:BYU IDAHO STUDENT HEALTH CENTER 179 CTR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83460-0001
Practice Address - Country:US
Practice Address - Phone:208-496-9341
Practice Address - Fax:208-496-9343
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist