Provider Demographics
NPI:1790273811
Name:AHWAH, SHAYNE MAHEALANI (PAC)
Entity Type:Individual
Prefix:
First Name:SHAYNE
Middle Name:MAHEALANI
Last Name:AHWAH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15700 SW GREYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6011
Mailing Address - Country:US
Mailing Address - Phone:971-262-9150
Mailing Address - Fax:971-262-9151
Practice Address - Street 1:15700 SW GREYSTONE CT
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-6011
Practice Address - Country:US
Practice Address - Phone:971-262-9150
Practice Address - Fax:971-262-9151
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA187846363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2099260Medicaid
OR500742931Medicaid