MEDICARE: SHAWN MICHAEL KOTLYN 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	367500000X	Certified Registered Nurse Anesthetist	RN268118 / NA06661	OH
2	367500000X	Certified Registered Nurse Anesthetist	RN572172	PA

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	:	1619991031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN MICHAEL KOTLYN CRNA

Provider Business Mailing Address
First Line	:	1414 HONEYGOLD LN
Second Line	:
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-3630
Country	:	US
Telephone Number	:	440-570-4022
Fax Number	:

Provider Business Practice Location Address
First Line	:	1414 HONEYGOLD LN
Second Line	:
City	:	BROADVIEW HEIGHTS
State	:	OH
Zip	:	44147-3630
Country	:	US
Telephone Number	:	440-570-4022
Fax Number	:

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	01/10/2014

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