Basic Information
Provider Information | |||||||||
NPI: | 1639106867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHAFFER | ||||||||
FirstName: | MELONY | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANDS | ||||||||
OtherFirstName: | MELONY | ||||||||
OtherMiddleName: | SUE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RPAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 134 HOMER AVE | ||||||||
Address2: |   | ||||||||
City: | CORTLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 130451206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077495708 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1104 COMMONS AVE | ||||||||
Address2: |   | ||||||||
City: | CORTLAND | ||||||||
State: | NY | ||||||||
PostalCode: | 130451643 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077583750 | ||||||||
FaxNumber: | 6077583754 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2006 | ||||||||
LastUpdateDate: | 03/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 006919-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 006919-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 1039516 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 02229050 | 05 | NY |   | MEDICAID |