Healthcare Provider Details

I. General information

NPI: 1730361577
Provider Name (Legal Business Name): SIMON-PETER SHAFFER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 HENDERSON CV RD
INDUSTRY ME
04938-4579
US

IV. Provider business mailing address

64 HENDERSON CV RD
INDUSTRY ME
04938-4579
US

V. Phone/Fax

Practice location:
  • Phone: 207-778-5542
  • Fax: 207-778-5580
Mailing address:
  • Phone: 207-778-5542
  • Fax: 207-778-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.003662
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA203
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: