Healthcare Provider Details

I. General information

NPI: 1194748673
Provider Name (Legal Business Name): SHAWN P. ROSS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N JACKSON ST
TULLAHOMA TN
37388-2201
US

IV. Provider business mailing address

744 W MICHIGAN AVE
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 931-393-7933
  • Fax:
Mailing address:
  • Phone: 800-242-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000152627
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11718
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: