Provider Demographics
NPI:1063567303
Name:SHAFER, GORDON SCOTT (FNP-C, OPA-C, CSA)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:SCOTT
Last Name:SHAFER
Suffix:
Gender:M
Credentials:FNP-C, OPA-C, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:BRICEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37710-0235
Mailing Address - Country:US
Mailing Address - Phone:865-426-9728
Mailing Address - Fax:
Practice Address - Street 1:116 E DIVISION RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6906
Practice Address - Country:US
Practice Address - Phone:865-483-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23329363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner