Provider Demographics
NPI:1669673349
Name:MOBILE PRIMARY CARE FAMILY NURSE PRACTITIONERS, PLLC
Entity Type:Organization
Organization Name:MOBILE PRIMARY CARE FAMILY NURSE PRACTITIONERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:716-893-1010
Mailing Address - Street 1:40 LA RIVIERE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4344
Mailing Address - Country:US
Mailing Address - Phone:716-893-1010
Mailing Address - Fax:716-893-1002
Practice Address - Street 1:640 ELLICOTT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1245
Practice Address - Country:US
Practice Address - Phone:716-893-1010
Practice Address - Fax:716-893-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333122363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG7101Medicare PIN
BA1182Medicare PIN