MEDICARE: MR. KETAN R SHAH 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	APRN9431447	FL
2	367500000X	Certified Registered Nurse Anesthetist	0024169375	VA

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	:	1922390210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KETAN R SHAH CRNA

Provider Business Mailing Address
First Line	:	3200 TYRE NECK RD
Second Line	:	SUITE 101
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-3329
Country	:	US
Telephone Number	:	757-399-7451
Fax Number	:	757-399-1158

Provider Business Practice Location Address
First Line	:	3200 TYRE NECK RD
Second Line	:	SUITE 101
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-3329
Country	:	US
Telephone Number	:	757-399-7451
Fax Number	:	757-399-1158

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

Provider Enumeration Date	:	05/05/2011
Last Update Date	:	02/19/2025

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