Provider Demographics
NPI:1205811312
Name:SHAFFER, JAMES CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CHRISTOPHER
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 17TH ST NW
Mailing Address - Street 2:BUILDING UNIT 417801 #6
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-6355
Mailing Address - Country:US
Mailing Address - Phone:507-440-0767
Mailing Address - Fax:
Practice Address - Street 1:1700 17TH ST NW
Practice Address - Street 2:BUILDING UNIT 417801 #6
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-6355
Practice Address - Country:US
Practice Address - Phone:507-440-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X
MN32355261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN274392200Medicaid
MN370004646OtherMEDICARE RAILROAD
MNE07131Medicare UPIN
MN274392200Medicaid