Provider Demographics
NPI:1225341308
Name:SHAFFER, ANDREW BRETT (ATC)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:BRETT
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 FROGS LEAP
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IN
Mailing Address - Zip Code:46034-9136
Mailing Address - Country:US
Mailing Address - Phone:765-210-0673
Mailing Address - Fax:
Practice Address - Street 1:8227 NORTHWEST BLVD STE 160
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1386
Practice Address - Country:US
Practice Address - Phone:317-415-5747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001038A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer