Provider Demographics
NPI:1952738148
Name:SHAFER, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SHAFER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:247 S BURNETT RD STE 210
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2663
Mailing Address - Country:US
Mailing Address - Phone:937-328-8850
Mailing Address - Fax:937-328-8860
Practice Address - Street 1:247 S BURNETT RD STE 210
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2663
Practice Address - Country:US
Practice Address - Phone:937-328-8850
Practice Address - Fax:937-328-8860
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0092432Medicaid
OHH192380Medicare PIN