Healthcare Provider Details

I. General information

NPI: 1083150064
Provider Name (Legal Business Name): SHANE JAMISON DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12809 DIAMOND LN
FORT SMITH AR
72916-4155
US

IV. Provider business mailing address

12809 DIAMOND LN
FORT SMITH AR
72916-4155
US

V. Phone/Fax

Practice location:
  • Phone: 918-721-3264
  • Fax:
Mailing address:
  • Phone: 918-721-3264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC003202
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: