Provider Demographics
NPI:1730361577
Name:SHAFFER, SIMON-PETER (PA)
Entity type:Individual
Prefix:
First Name:SIMON-PETER
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 HENDERSON CV RD
Mailing Address - Street 2:
Mailing Address - City:INDUSTRY
Mailing Address - State:ME
Mailing Address - Zip Code:04938-4579
Mailing Address - Country:US
Mailing Address - Phone:207-778-5542
Mailing Address - Fax:207-778-5580
Practice Address - Street 1:64 HENDERSON CV RD
Practice Address - Street 2:
Practice Address - City:INDUSTRY
Practice Address - State:ME
Practice Address - Zip Code:04938-4579
Practice Address - Country:US
Practice Address - Phone:207-778-5542
Practice Address - Fax:207-778-5580
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA203363AM0700X
IL085.003662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME2191Medicaid
MEME2191Medicaid