Provider Demographics
NPI:1639109051
Name:SHAFFER, DONALD (PA-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 RESEARCH PARK DRIVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4664
Mailing Address - Country:US
Mailing Address - Phone:248-668-8650
Mailing Address - Fax:248-668-8651
Practice Address - Street 1:41100 FOX RUN
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-4804
Practice Address - Country:US
Practice Address - Phone:248-668-8650
Practice Address - Fax:248-668-8651
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002860363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
83-05251OtherEVERCARE
DS002860OtherBCBS MI
1158217680OtherBCBS MI
83-05251OtherEVERCARE
M99950013Medicare PIN
DS002860OtherBCBS MI