Provider Demographics
NPI:1356593610
Name:SHAY, EMMA JEAN
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:JEAN
Last Name:SHAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:JEAN
Other - Last Name:SHAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80150-1175
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-651-5000
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002583363A00000X
CO2583363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COA001030353Medicaid
CA99721066Medicaid
COCOAAA0731Medicare PIN