Provider Demographics
NPI:1265619118
Name:SHAW, JERRY EMERSON (PA-C)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:EMERSON
Last Name:SHAW
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5705 STAGE RD
Mailing Address - Street 2:STE 240
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-4541
Mailing Address - Country:US
Mailing Address - Phone:901-382-2606
Mailing Address - Fax:901-373-0809
Practice Address - Street 1:3980 NEW COVINGTON PIKE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-2514
Practice Address - Country:US
Practice Address - Phone:901-937-3232
Practice Address - Fax:901-373-0804
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN815363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical