Provider Demographics
NPI:1922304161
Name:SHAFFER, RICKY ALAN (CDRS)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:ALAN
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:CDRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UNIVERSITY DR
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:717-531-0138
Practice Address - Street 1:30 HOPE DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2036
Practice Address - Country:US
Practice Address - Phone:717-531-7105
Practice Address - Fax:717-531-0138
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA21364278172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver