Provider Demographics
NPI:1730181561
Name:SHAFER, SHAUN STUART (MD)
Entity type:Individual
Prefix:DR
First Name:SHAUN
Middle Name:STUART
Last Name:SHAFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MCCOLLUM DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5103
Mailing Address - Country:US
Mailing Address - Phone:307-742-2131
Mailing Address - Fax:307-742-2134
Practice Address - Street 1:204 MCCOLLUM DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5103
Practice Address - Country:US
Practice Address - Phone:307-742-2131
Practice Address - Fax:307-742-2134
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2019-12-19
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
WY5934A156FX1100X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118240400Medicaid
180046305OtherRAILROAD MEDICARE
180046305OtherRAILROAD MEDICARE
9521Medicare ID - Type Unspecified