Provider Demographics
NPI:1942603097
Name:SHAW, AMY SCOTT (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SCOTT
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6108 SHANNON AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3537
Mailing Address - Country:US
Mailing Address - Phone:619-962-5026
Mailing Address - Fax:307-263-7546
Practice Address - Street 1:6108 SHANNON AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3537
Practice Address - Country:US
Practice Address - Phone:619-962-5026
Practice Address - Fax:307-263-7546
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT615363A00000X
WYPA615363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant