Provider Demographics
NPI:1033287271
Name:SHABAZZ, AFFIVIA DAVIES (APRN-CS)
Entity Type:Individual
Prefix:
First Name:AFFIVIA
Middle Name:DAVIES
Last Name:SHABAZZ
Suffix:
Gender:F
Credentials:APRN-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:920 2ND AVE S
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-3318
Mailing Address - Country:US
Mailing Address - Phone:612-659-7111
Mailing Address - Fax:612-225-1591
Practice Address - Street 1:920 2ND AVE S
Practice Address - Street 2:SUITE 400
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-3318
Practice Address - Country:US
Practice Address - Phone:612-659-7111
Practice Address - Fax:612-225-1591
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN186391NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBKVCMedicare UPIN