Basic Information
Provider Information | |||||||||
NPI: | 1275899635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAFFER | ||||||||
FirstName: | ANDRE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18444 N 25TH AVE STE 310 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850231266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6697426738 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Practice Location | |||||||||
Address1: | 18444 N 25TH AVE STE 210 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850231264 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6697426738 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2012 | ||||||||
LastUpdateDate: | 08/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | 272861 | NY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | MD60858779 | WA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0801X | 270904 | MA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0801X | 66323 | AZ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
No ID Information.