Healthcare Provider Details

I. General information

NPI: 1225087505
Provider Name (Legal Business Name): JOHN N SHELLENBERGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1687
US

IV. Provider business mailing address

PO BOX 608
JORDAN NY
13080
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7828
  • Fax: 315-470-5811
Mailing address:
  • Phone: 731-415-3389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number300825
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: