Provider Demographics
NPI:1023260783
Name:REYNOLDS, SHAWNA MARIE (PA)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-0000
Mailing Address - Country:US
Mailing Address - Phone:208-785-2600
Mailing Address - Fax:208-234-0026
Practice Address - Street 1:1441 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-0000
Practice Address - Country:US
Practice Address - Phone:208-785-2600
Practice Address - Fax:208-785-1762
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-778363AM0700X
IDPA778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical