Healthcare Provider Details

I. General information

NPI: 1114084316
Provider Name (Legal Business Name): JOHN J SHAFF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16611 S. 40TH ST SUITE 100
PHOENIX AZ
85048
US

IV. Provider business mailing address

16611 S. 40TH ST SUITE 100
PHOENIX AZ
85048
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6366
  • Fax: 480-833-1653
Mailing address:
  • Phone: 480-610-6366
  • Fax: 480-833-1653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3149
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: