Healthcare Provider Details

I. General information

NPI: 1720099542
Provider Name (Legal Business Name): MANARDIE FRANCIS SHIMATA DNAP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3773 CHERRY HILLS CIR
SYRACUSE UT
84075-8402
US

IV. Provider business mailing address

3773 CHERRY HILLS CIR
SYRACUSE UT
84075-8402
US

V. Phone/Fax

Practice location:
  • Phone: 801-786-9233
  • Fax:
Mailing address:
  • Phone: 801-786-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number164348
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30006270
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number277586-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: