Basic Information
Provider Information | |||||||||
NPI: | 1457330532 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCBRIDE | ||||||||
FirstName: | SHAUNA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 168 N 100 E | ||||||||
Address2: |   | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847702893 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4359862565 | ||||||||
FaxNumber: | 4359862577 | ||||||||
Practice Location | |||||||||
Address1: | 168 N 100 E | ||||||||
Address2: |   | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847702893 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4359862565 | ||||||||
FaxNumber: | 4359862577 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 03/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 58509011206 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 352163112003 | 05 | UT |   | MEDICAID | 461819 | 01 | UT | MEDICARE UGS | OTHER | 352163112017 | 01 |   | MEDICAID PCN | OTHER | 000057177 | 01 |   | MEDICARE B | OTHER |