Provider Demographics
NPI:1639856404
Name:SHAFFER, LISSA (FNP-BC, MSN, R)
Entity Type:Individual
Prefix:MRS
First Name:LISSA
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:FNP-BC, MSN, R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 S PACHECO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6103
Mailing Address - Country:US
Mailing Address - Phone:505-477-2200
Mailing Address - Fax:
Practice Address - Street 1:2085 S PACHECO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6103
Practice Address - Country:US
Practice Address - Phone:505-477-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74136363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner