Provider Demographics
NPI:1003427006
Name:SHAFFER, TRAVIS WADE
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WADE
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 E WHITMORE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-2800
Mailing Address - Country:US
Mailing Address - Phone:209-264-8934
Mailing Address - Fax:
Practice Address - Street 1:2908 E WHITMORE AVE STE E
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-2800
Practice Address - Country:US
Practice Address - Phone:209-264-8934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50546225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant