Basic Information
| Provider Information | |||||||||
| NPI: | 1699024505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAVER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WEST TIETAN | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993620309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095221593 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 W TIETAN ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253720 | ||||||||
| FaxNumber: | 5095221593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA60310476 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA60310476 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2013653 | 05 | WA | MEDICAID |