Healthcare Provider Details

I. General information

NPI: 1972223337
Provider Name (Legal Business Name): SHANE MICHAEL PENDLETON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MILL AVE
TEMPE AZ
85281-6699
US

IV. Provider business mailing address

242 S BECK AVE APT 231
TEMPE AZ
85281-2478
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-5500
  • Fax:
Mailing address:
  • Phone: 805-914-4081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number228767
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number153800
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: