Provider Demographics
NPI:1659552511
Name:GAFFORD, KAREN D (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:D
Last Name:GAFFORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:D
Other - Last Name:SHOCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:14200 W CELEBRATE LIFE WAY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338
Mailing Address - Country:US
Mailing Address - Phone:623-207-3832
Mailing Address - Fax:623-932-8592
Practice Address - Street 1:14200 W CELEBRATE LIFE WAY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338
Practice Address - Country:US
Practice Address - Phone:623-207-3062
Practice Address - Fax:623-932-8592
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
887581133V00000X
COPA.0003585363A00000X
AZ6247363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95509291Medicaid
CO95509291Medicaid
COP01181183Medicare PIN