Provider Demographics
NPI:1184674749
Name:SHAFER, AMANDA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BETH
Last Name:SHAFER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 WHITE TAIL DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5868
Mailing Address - Country:US
Mailing Address - Phone:423-360-4845
Mailing Address - Fax:
Practice Address - Street 1:2347 ROSSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408-2250
Practice Address - Country:US
Practice Address - Phone:423-265-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4212363AS0400X
TN1089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ03886Medicare UPIN