Provider Demographics
NPI:1912061466
Name:SHAFFER, MARY J (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5101
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:
Practice Address - Street 1:722 S WAHSATCH AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4035
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7828
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO63257363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01771582Medicaid
COCOA 101807Medicare UPIN