Provider Demographics
NPI:1316289150
Name:MCKINNON SHAW, KRISTEN (MD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:MCKINNON SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E MISSOURI AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:480-500-2540
Mailing Address - Fax:623-201-7954
Practice Address - Street 1:9201 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3332
Practice Address - Country:US
Practice Address - Phone:480-500-2540
Practice Address - Fax:623-201-7954
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZAZ51534207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program