Provider Demographics
NPI:1083361257
Name:MARTIN, SHANE TYLER (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:TYLER
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 RAHLING RD APT 2420
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-5297
Mailing Address - Country:US
Mailing Address - Phone:580-774-9274
Mailing Address - Fax:
Practice Address - Street 1:701 RAHLING RD APT 2420
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-5297
Practice Address - Country:US
Practice Address - Phone:580-774-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR220519367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered