MEDICARE: BRENDA J SHAW PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA587	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679642037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA J SHAW PA

Provider Business Mailing Address
First Line	:	1660 JOHN ADAMS PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4360
Country	:	US
Telephone Number	:	208-523-8844
Fax Number	:	208-529-8684

Provider Business Practice Location Address
First Line	:	1660 JOHN ADAMS PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4360
Country	:	US
Telephone Number	:	208-523-8844
Fax Number	:	208-529-8684

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	12/15/2009

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Directions to “ BRENDA J SHAW PA” Practice Location

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