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NPI Code Detail

MEDICARE: KELLY RAY SHANTZ CRNA

MEDICARE: KELLY RAY SHANTZ CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse AnesthetistR 162289-8MN
2367500000XCertified Registered Nurse Anesthetist868MN

General Provider Information

NPI Number : 1477540995
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY RAY SHANTZ CRNA
Provider Business Mailing Address
First Line : 800 MEDICAL CENTER DR
Second Line :
City : FAIRMONT
State : MN
Zip : 56031-4575
Country : US
Telephone Number : 507-238-8555
Fax Number :
Provider Business Practice Location Address
First Line : 800 MEDICAL CENTER DR
Second Line :
City : FAIRMONT
State : MN
Zip : 56031-4575
Country : US
Telephone Number : 507-238-8555
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/29/2005
Last Update Date : 09/17/2020

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Directions to “ KELLY RAY SHANTZ CRNA” Practice Location

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