Provider Demographics
NPI:1477225894
Name:SHAW, KENDRA (PA-C)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 CORNFIELD WAY APT 303
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-7235
Mailing Address - Country:US
Mailing Address - Phone:330-608-3220
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0001
Practice Address - Country:US
Practice Address - Phone:570-808-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant