Provider Demographics
NPI:1255332748
Name:SHAFFER, MICHELLE RAE (MPA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RAE
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37086
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3086
Mailing Address - Country:US
Mailing Address - Phone:240-439-8913
Mailing Address - Fax:240-439-8910
Practice Address - Street 1:7211 BANK CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703
Practice Address - Country:US
Practice Address - Phone:240-215-6370
Practice Address - Fax:240-439-8910
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051493363A00000X
MDC0003226363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA074591JJ0Medicare ID - Type Unspecified
PAQ06381Medicare UPIN