Provider Demographics
NPI:1881626562
Name:SHAFFER, SCOTT K
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:K
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3863 SW LOOP 820
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-2064
Mailing Address - Country:US
Mailing Address - Phone:877-294-7444
Mailing Address - Fax:
Practice Address - Street 1:448 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2804
Practice Address - Country:US
Practice Address - Phone:719-539-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO165807367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59338547Medicaid
COC800198Medicare ID - Type Unspecified