Healthcare Provider Details

I. General information

NPI: 1083931034
Provider Name (Legal Business Name): ADAM SHANE DAVID CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 N 12TH ST # 230
MURRAY KY
42071-1651
US

IV. Provider business mailing address

632 N 12TH ST # 230
MURRAY KY
42071-1651
US

V. Phone/Fax

Practice location:
  • Phone: 859-948-8389
  • Fax:
Mailing address:
  • Phone: 859-948-8389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3006454
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: