Provider Demographics
NPI:1255450169
Name:SHAVER, KRISTINE LEA (PS)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LEA
Last Name:SHAVER
Suffix:
Gender:F
Credentials:PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-1023
Mailing Address - Country:US
Mailing Address - Phone:515-795-4300
Mailing Address - Fax:
Practice Address - Street 1:623 W NORTH ST
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:IA
Practice Address - Zip Code:50156-1023
Practice Address - Country:US
Practice Address - Phone:515-795-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI12096Medicare PIN