Provider Demographics
NPI:1598173056
Name:SHAFER, WHITNEY J (NP)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:J
Last Name:SHAFER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 BENNETT DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:IN
Practice Address - Zip Code:46792
Practice Address - Country:US
Practice Address - Phone:260-375-3670
Practice Address - Fax:260-375-3669
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005021A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201254970Medicaid
IN260690037Medicare PIN