MEDICARE: JOHN SHANE MALLETT 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
1	207L00000X	Anesthesiology Physician	RN085277	LA
2	367500000X	Certified Registered Nurse Anesthetist	AP121182	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306021282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN SHANE MALLETT CRNA

Provider Business Mailing Address
First Line	:	751 BAYOU PINES EAST DR
Second Line	:	SUITE L
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-7196
Country	:	US
Telephone Number	:	337-436-8700
Fax Number	:	337-436-3008

Provider Business Practice Location Address
First Line	:	751 BAYOU PINES EAST DR
Second Line	:	SUITE L
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-7196
Country	:	US
Telephone Number	:	337-436-8700
Fax Number	:	337-436-3008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2008
Last Update Date	:	12/29/2022

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