Healthcare Provider Details

I. General information

NPI: 1164494381
Provider Name (Legal Business Name): ROBERT MICHAEL SHEPPARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 WEST 9TH
HOISINGTON KS
67544
US

IV. Provider business mailing address

PO BOX 388
NEWTON KS
67114-0388
US

V. Phone/Fax

Practice location:
  • Phone: 620-653-2114
  • Fax:
Mailing address:
  • Phone: 316-281-3700
  • Fax: 316-282-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54239
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: