Provider Demographics
NPI:1164458857
Name:SHACKFORD, BARBARA (CRNA)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:SHACKFORD
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 1:375 ENGLE ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1823
Mailing Address - Country:US
Mailing Address - Phone:201-871-6073
Mailing Address - Fax:201-655-6159
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3238
Practice Address - Fax:201-894-0585
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR06705800367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ430062618OtherRAILROAD MEDICARE
NJ046399Medicare PIN