Provider Demographics
NPI:1144217340
Name:EDDY, SHANNON R (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:EDDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 AVERY ST STE 501
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5192
Mailing Address - Country:US
Mailing Address - Phone:304-422-3904
Mailing Address - Fax:304-422-3924
Practice Address - Street 1:800 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5340
Practice Address - Country:US
Practice Address - Phone:304-424-2590
Practice Address - Fax:304-422-3924
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA06071367500000X
WV21306367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0067769000Medicaid
OH0767433Medicaid
8205933Medicare ID - Type Unspecified