Healthcare Provider Details

I. General information

NPI: 1659552511
Provider Name (Legal Business Name): KAREN D GAFFORD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN D SHOCKLEY RD

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14200 W CELEBRATE LIFE WAY
GOODYEAR AZ
85338
US

IV. Provider business mailing address

14200 W CELEBRATE LIFE WAY
GOODYEAR AZ
85338
US

V. Phone/Fax

Practice location:
  • Phone: 623-207-3062
  • Fax: 623-932-8592
Mailing address:
  • Phone: 623-207-3832
  • Fax: 623-932-8592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003585
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6247
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number887581
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: