Provider Demographics
NPI:1083931034
Name:DAVID, ADAM SHANE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:SHANE
Last Name:DAVID
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 1:632 N 12TH ST # 230
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-1651
Mailing Address - Country:US
Mailing Address - Phone:859-948-8389
Mailing Address - Fax:
Practice Address - Street 1:632 N 12TH ST # 230
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1651
Practice Address - Country:US
Practice Address - Phone:859-948-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006454367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK014590Medicare Oscar/Certification