Provider Demographics
NPI:1205195278
Name:SHAFER, THOMAS G (NPP-BC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:SHAFER
Suffix:
Gender:M
Credentials:NPP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 WILLOWBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420
Mailing Address - Country:US
Mailing Address - Phone:585-953-6405
Mailing Address - Fax:
Practice Address - Street 1:350 NEW CAMPUS DR
Practice Address - Street 2:SUNY COLLEGE AT BROCKPORT
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:15520
Practice Address - Country:US
Practice Address - Phone:585-395-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY586940163WP0808X
NY401602363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY401602OtherNURSE PRACTITIONER- PSYCHIATRY LICENSE NUMBER
NY586940OtherRN LICENSE