Provider Demographics
NPI:1356777353
Name:SHAFER, THERESA ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:SHAFER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:DIJOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:479 THOMAS JONES WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341
Mailing Address - Country:US
Mailing Address - Phone:267-582-6467
Mailing Address - Fax:215-615-1294
Practice Address - Street 1:479 THOMAS JONES WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341
Practice Address - Country:US
Practice Address - Phone:267-582-6467
Practice Address - Fax:215-615-1294
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056359363A00000X
NJ25MP00347500363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA325628Q7RMedicare PIN