Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 42452 | MN |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 42452 | MN |
NPI | 1427167691 |
---|---|
Provider Name | Joseph Jacob Shaffer |
First Address | Saint Paul, MN 55107-1827 |
Second Address | Eagan, MN 55123-1033 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 28/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
061605200 | (05) | MN |