Healthcare Provider Details

I. General information

NPI: 1063137677
Provider Name (Legal Business Name): SHANE RICHARD SMITH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COWLES ST
FAIRBANKS AK
99701-5907
US

IV. Provider business mailing address

2 N 3000 E
SUGAR CITY ID
83448-1220
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-8181
  • Fax:
Mailing address:
  • Phone: 360-600-7852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number145179
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: