Provider Demographics
NPI:1427526037
Name:SHAW, AUDREY JEAN (PA)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JEAN
Last Name:SHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:JEAN
Other - Last Name:PATTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8354 100TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:MI
Practice Address - Zip Code:49346-8345
Practice Address - Country:US
Practice Address - Phone:231-972-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty