Provider Demographics
NPI:1649607284
Name:SHAW, AUDREY LYNN (PA-C)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1001 ROUTE 73 N UPPR LEVELB
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4524
Practice Address - Country:US
Practice Address - Phone:856-355-7137
Practice Address - Fax:856-355-7138
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003112363A00000X
PAMA056344363AM0700X
NJ25MP00544000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical