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NPI Code Detail

MEDICARE: MRS. TINA NANNETTE SHANNON CRNA

MEDICARE: MRS. TINA NANNETTE SHANNON CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse Anesthetist54626WV

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
5P00258571OTHERWVMEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
127005299700OTHERWVWORKER'S COMP-MAAC
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3270052997OTHERWVTAX ID -MAAC
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6001713630OTHERWVBCBS-MAAC

General Provider Information

NPI Number : 1265435556
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. TINA NANNETTE SHANNON CRNA
Provider Business Mailing Address
First Line : 311 SOUTHPOINTE DR
Second Line :
City : CHARLESTON
State : WV
Zip : 25314-2471
Country : US
Telephone Number : 304-546-3081
Fax Number :
Provider Business Practice Location Address
First Line : 3200 MACCORKLE AVE SE
Second Line :
City : CHARLESTON
State : WV
Zip : 25304-1227
Country : US
Telephone Number : 304-388-5503
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/31/2005
Last Update Date : 04/17/2024

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