Provider Demographics
NPI:1396358438
Name:SHAFFER, JOHN WAYNE (LPN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYNE
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7231
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:
Practice Address - Street 1:500 W FRONT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7231
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54544164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID54544OtherVETERANS ADMINISTRATION
ID54544OtherIDAHO BAORD OF NURSING