Provider Demographics
NPI:1518943810
Name:SHAFNACKER, WILLIAM MICHAEL (PAC MHP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:SHAFNACKER
Suffix:
Gender:M
Credentials:PAC MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:CT
Mailing Address - Zip Code:06413-1301
Mailing Address - Country:US
Mailing Address - Phone:860-669-4209
Mailing Address - Fax:860-669-4209
Practice Address - Street 1:6 BUSINESS PARK DR STE 302
Practice Address - Street 2:STONY CREEK URGENT CARE
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2988
Practice Address - Country:US
Practice Address - Phone:203-483-4580
Practice Address - Fax:203-483-4581
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001195363A00000X
MA789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S34204Medicare UPIN
CT970001842Medicare ID - Type Unspecified