Provider Demographics
NPI:1881419604
Name:SHAFER, HEIDI MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:MARIE
Last Name:SHAFER
Suffix:
Gender:F
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 1:500 BUFFALO TOM DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-8344
Mailing Address - Country:US
Mailing Address - Phone:770-905-3779
Mailing Address - Fax:
Practice Address - Street 1:612 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-2465
Practice Address - Country:US
Practice Address - Phone:740-315-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1219220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant