Individual
EVERETT LEE SHAW
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
4775 E MARYLAND ST, DECATUR, IL 62521-8820
(217) 864-3737
(217) 864-3468
Mailing address
517 N MAIN ST, ANNA, IL 62906-1668
(618) 833-4300
(618) 833-9058
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085.004037
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1051123
NCCAP NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
—
01
—
205790002
MEDICARE PTAN
IL
Enumeration date
06/10/2011
Last updated
01/17/2023
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