Healthcare Provider Details

I. General information

NPI: 1619991031
Provider Name (Legal Business Name): SHAWN MICHAEL KOTLYN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 HONEYGOLD LN
BROADVIEW HEIGHTS OH
44147-3630
US

IV. Provider business mailing address

1414 HONEYGOLD LN
BROADVIEW HEIGHTS OH
44147-3630
US

V. Phone/Fax

Practice location:
  • Phone: 440-570-4022
  • Fax:
Mailing address:
  • Phone: 440-570-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN268118 / NA06661
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN572172
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: