Provider Demographics
NPI:1679953780
Name:SHAFFER, ASA MONTANA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ASA
Middle Name:MONTANA
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:509 S BROADWAY
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:MO
Practice Address - Zip Code:64075-9627
Practice Address - Country:US
Practice Address - Phone:816-625-4967
Practice Address - Fax:816-625-8376
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027142225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist