Healthcare Provider Details

I. General information

NPI: 1467575894
Provider Name (Legal Business Name): LYDA A SHAMBO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1602
US

IV. Provider business mailing address

420 CENTRAL PARK W APT. 4G
NEW YORK NY
10025-4375
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7111
  • Fax:
Mailing address:
  • Phone: 917-455-3722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001204398
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number525267
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024167441
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number525267
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: