Provider Demographics
NPI:1679030852
Name:SHAFFER, BRADEN J (APN)
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:J
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6014
Mailing Address - Fax:904-450-6401
Practice Address - Street 1:3871 E HIGHWAY 98 STE 203
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5302
Practice Address - Country:US
Practice Address - Phone:850-229-5661
Practice Address - Fax:850-229-5662
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018862363L00000X
FLAPRN11004356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner