Provider Demographics
NPI:1740761519
Name:SHAFFER, ALEX RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:RENEE
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 CORPORATE CIR STE 300
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7760
Mailing Address - Country:US
Mailing Address - Phone:702-910-3950
Mailing Address - Fax:
Practice Address - Street 1:1813 W HARVARD AVE STE 434
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8705
Practice Address - Country:US
Practice Address - Phone:541-957-0111
Practice Address - Fax:541-957-0333
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA196705OtherSTATE LICENSE
OR500777629Medicaid