Provider Demographics
NPI:1053585562
Name:SHAFFER, ROSE B (CRNP)
Entity type:Individual
Prefix:MS
First Name:ROSE
Middle Name:B
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST RM 5480G
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-8408
Mailing Address - Fax:215-503-7784
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:ROOM 1900 GIBBON
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-8408
Practice Address - Fax:215-955-8966
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP004716P363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103144230Medicaid
PA487271Medicare PIN