Provider Demographics
NPI:1679053813
Name:SHAFFER, RYAN MATTHEW (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MATTHEW
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3754
Mailing Address - Country:US
Mailing Address - Phone:573-202-3166
Mailing Address - Fax:
Practice Address - Street 1:11445 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7108
Practice Address - Country:US
Practice Address - Phone:314-428-9543
Practice Address - Fax:314-428-9542
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018030484363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily