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General NPI Number Information
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NPI Number | 1700865904
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Entity Type | Individual
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Provider Name | KIMBERLY ANN SHAW PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/16/2006
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Last Update Date | 04/23/2012
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Provider Practice Location Address
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Address Line | 200 CODY RD S
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City | LE CLAIRE
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State | IA
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Zip | 52753-9579
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Country | US
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Telephone | 563-289-2273
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Fax | 563-289-1605
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Provider Business Mailing Address
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Address Line | 11532 61ST AVE
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City | BLUE GRASS
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State | IA
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Zip | 52726-9660
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Country | US
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Telephone | 563-381-5041
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 001653
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 005650
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License Number State | GA
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