=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689652133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM E SHAW JR. PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2006
-----------------------------------------------------
Last Update Date | 09/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 E 1ST ST STE 326
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-285-5800
-----------------------------------------------------
Fax | 815-285-5821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 E 1ST ST STE 326
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-285-5800
-----------------------------------------------------
Fax | 815-285-5821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2014016131
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 085.006207
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------