Provider Demographics
NPI:1245949239
Name:SHOPTAW, SAMUEL CHASE I (APRN, FNP-C)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:CHASE
Last Name:SHOPTAW
Suffix:I
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CAPTAIN FRANK RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-5047
Mailing Address - Country:US
Mailing Address - Phone:502-435-9542
Mailing Address - Fax:
Practice Address - Street 1:3900 KRESGE WAY STE 51
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4683
Practice Address - Country:US
Practice Address - Phone:502-899-3623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily