Provider Demographics
NPI:1194074815
Name:SHAW, AMANDA JO (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:MCMAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2180 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1625
Mailing Address - Country:US
Mailing Address - Phone:808-242-6464
Mailing Address - Fax:
Practice Address - Street 1:2180 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1625
Practice Address - Country:US
Practice Address - Phone:808-242-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363A00000X
HIAMD-794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant