Healthcare Provider Details

I. General information

NPI: 1700865904
Provider Name (Legal Business Name): KIMBERLY ANN SHAW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CODY RD S
LE CLAIRE IA
52753-9579
US

IV. Provider business mailing address

11532 61ST AVE
BLUE GRASS IA
52726-9660
US

V. Phone/Fax

Practice location:
  • Phone: 563-289-2273
  • Fax: 563-289-1605
Mailing address:
  • Phone: 563-381-5041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001653
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005650
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: