1407179690 NPI number — CHRISTOPHER JOEL SHAW PA-C

Table of content: CHRISTOPHER JOEL SHAW PA-C (NPI 1407179690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407179690 NPI number — CHRISTOPHER JOEL SHAW PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
CHRISTOPHER
Provider Middle Name:
JOEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407179690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13236 NE 129TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034-3361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-814-5100
Provider Business Mailing Address Fax Number:
425-814-5103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11800 NE 128TH ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
KIRKLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98034-7208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-814-5100
Provider Business Practice Location Address Fax Number:
425-814-5103
Provider Enumeration Date:
03/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA60124508 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00946049 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0260915 . This is a "L AND I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1407179690 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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