MEDICARE: TIMOTHY D SHIELDS 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
1	367500000X	Certified Registered Nurse Anesthetist	R0064541	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	OK401908	OTHER	OK	MEDICARE ID-TYPE UNSPECIFIED

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851347546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY D SHIELDS CRNA

Provider Business Mailing Address
First Line	:	PO BOX 5978
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73403-0978
Country	:	US
Telephone Number	:	580-226-5000
Fax Number	:	580-226-5035

Provider Business Practice Location Address
First Line	:	2412 N COMMERCE ST
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1356
Country	:	US
Telephone Number	:	580-226-5000
Fax Number	:	580-226-5035

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	10/01/2009

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Directions to “ TIMOTHY D SHIELDS CRNA” Practice Location

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