Healthcare Provider Details

I. General information

NPI: 1497747745
Provider Name (Legal Business Name): LADD SHANER C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W WASHINGTON ST
BURNS OR
97720
US

IV. Provider business mailing address

8766 GALLOWAY TRL
NOVELTY OH
44072-9653
US

V. Phone/Fax

Practice location:
  • Phone: 541-573-7281
  • Fax:
Mailing address:
  • Phone: 440-338-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.02531
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201805701CRNA-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: