Healthcare Provider Details

I. General information

NPI: 1225518509
Provider Name (Legal Business Name): KYLEE SHAW PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 FALLS AVE E STE 1002
TWIN FALLS ID
83301-3459
US

IV. Provider business mailing address

147 W CHUBBUCK RD
CHUBBUCK ID
83202-2314
US

V. Phone/Fax

Practice location:
  • Phone: 208-595-5424
  • Fax:
Mailing address:
  • Phone: 208-238-7546
  • Fax: 208-237-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: