Healthcare Provider Details

I. General information

NPI: 1417926130
Provider Name (Legal Business Name): SHAWN THOMAS GAUGHAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 SHELDON ST
SAINT PAUL MN
55108-2331
US

IV. Provider business mailing address

1544 SHELDON ST
SAINT PAUL MN
55108-2331
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-3091
  • Fax: 651-646-3124
Mailing address:
  • Phone: 651-646-3091
  • Fax: 651-646-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 139202-1
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN223809
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: