Provider Demographics
NPI:1538782677
Name:SHAFFER, KELLEY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:SHAFFER
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 1:3220 PARKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-1917
Mailing Address - Country:US
Mailing Address - Phone:972-668-3990
Mailing Address - Fax:
Practice Address - Street 1:3220 PARKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-1917
Practice Address - Country:US
Practice Address - Phone:972-668-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA13393OtherPHYSICIAN ASSISTANT LICENSE
TXPA13393OtherPHYSICIAN ASSISTANT LICENSE