Provider Demographics
NPI:1265577811
Name:ALLEN, SHAWN GILLETT (PA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:GILLETT
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5950
Mailing Address - Fax:208-302-5955
Practice Address - Street 1:10583 W LAKE HAZEL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-302-5950
Practice Address - Fax:208-302-5955
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA211907363A00000X
363AM0700X
IDPA-886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical