Provider Demographics
NPI:1942454186
Name:SHAW, KIMBERLY DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANIELLE
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DANIELLE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:31 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3556
Mailing Address - Country:US
Mailing Address - Phone:708-596-5177
Mailing Address - Fax:708-596-5518
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-3556
Practice Address - Country:US
Practice Address - Phone:708-596-5177
Practice Address - Fax:708-596-5518
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003355Medicaid
IL01616617OtherBCBS