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:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0579
Mailing Address - Country:US
Mailing Address - Phone:541-766-6835
Mailing Address - Fax:541-766-6164
Practice Address - Street 1:610 DRAGON DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OR
Practice Address - Zip Code:97456-9604
Practice Address - Country:US
Practice Address - Phone:541-766-6000
Practice Address - Fax:541-766-6047
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2024-12-18
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