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General NPI Number Information
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NPI Number | 1679642037
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Entity Type | Individual
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Provider Name | BRENDA J SHAW PA
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Gender | Female
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 12/15/2009
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Provider Practice Location Address
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Address Line | 1660 JOHN ADAMS PKWY
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4360
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Country | US
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Telephone | 208-523-8844
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Fax | 208-529-8684
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Provider Business Mailing Address
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Address Line | 1660 JOHN ADAMS PKWY
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City | IDAHO FALLS
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State | ID
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Zip | 83401-4360
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Country | US
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Telephone | 208-523-8844
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Fax | 208-529-8684
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA587
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License Number State | ID
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