Healthcare Provider Details

I. General information

NPI: 1437241247
Provider Name (Legal Business Name): BYRON RUSSELL SHANNON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 2ND ST
RICHLAND CENTER WI
53581-1914
US

IV. Provider business mailing address

201 N STEWART ST
RICHLAND CENTER WI
53581-1323
US

V. Phone/Fax

Practice location:
  • Phone: 608-647-6321
  • Fax:
Mailing address:
  • Phone: 608-647-6522
  • Fax: 608-647-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number46278-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: