Healthcare Provider Details

I. General information

NPI: 1407206485
Provider Name (Legal Business Name): HAGENT LAWRENCE SHUE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19304 AVENIDA DEL SOL
WALNUT CA
91789-1639
US

IV. Provider business mailing address

19304 AVENIDA DEL SOL
WALNUT CA
91789-1639
US

V. Phone/Fax

Practice location:
  • Phone: 310-962-2867
  • Fax:
Mailing address:
  • Phone: 310-962-2867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066401
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53904
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3060
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: