Healthcare Provider Details

I. General information

NPI: 1164640926
Provider Name (Legal Business Name): SHANE D FALTYS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3396
US

IV. Provider business mailing address

12747 FOXWOOD PT
POPLAR BLUFF MO
63901-7746
US

V. Phone/Fax

Practice location:
  • Phone: 573-718-2710
  • Fax:
Mailing address:
  • Phone: 573-778-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2004031200
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD-102109
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: