Provider Demographics
NPI:1689652133
Name:SHAW, WILLIAM E JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:E
Last Name:SHAW
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 1ST ST STE 326
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3190
Mailing Address - Country:US
Mailing Address - Phone:815-285-5800
Mailing Address - Fax:815-285-5821
Practice Address - Street 1:215 E 1ST ST STE 326
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3190
Practice Address - Country:US
Practice Address - Phone:815-285-5800
Practice Address - Fax:815-285-5821
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014016131363A00000X
363A00000X
IL085.006207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400478683OtherMEDICARE PTAN
ILF400478683OtherMEDICARE PTAN