Provider Demographics
NPI:1669542635
Name:SHAFER, KAROLE M (ACNP)
Entity type:Individual
Prefix:
First Name:KAROLE
Middle Name:M
Last Name:SHAFER
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 FREY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513
Mailing Address - Country:US
Mailing Address - Phone:315-331-4344
Mailing Address - Fax:315-331-1211
Practice Address - Street 1:201 FREY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-331-4344
Practice Address - Fax:315-331-1211
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF4302391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P019430239OtherEXCELLUS BLUE CHOICE
153752B0OtherPREFERRED CARE
25849Medicare UPIN
RA4668Medicare ID - Type Unspecified