Basic Information
| Provider Information | |||||||||
| NPI: | 1679030852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAFFER | ||||||||
| FirstName: | BRADEN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506014 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 3871 E HIGHWAY 98 STE 203 | ||||||||
| Address2: | |||||||||
| City: | PORT ST JOE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324565302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502295661 | ||||||||
| FaxNumber: | 8502295662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2019 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209018862 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN11004356 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.