Individual
TRENT E SHAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
72 E MAIN ST, REXBURG, ID 83440-1926
(208) 359-1770
(208) 359-1780
Mailing address
72 E MAIN ST, REXBURG, ID 83440-1926
(208) 359-1770
(208) 359-1780
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA-308
ID
363AM0700X
Medical Physician Assistant
Primary
PA-308
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
806887500
—
ID
Enumeration date
06/21/2006
Last updated
09/30/2011
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