Provider Demographics
NPI:1164487351
Name:SHAVER, RANDY R (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:R
Last Name:SHAVER
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 1:40 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2802
Mailing Address - Country:US
Mailing Address - Phone:413-569-0964
Mailing Address - Fax:
Practice Address - Street 1:1 HUMMINGBIRD HOLW
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077-9530
Practice Address - Country:US
Practice Address - Phone:413-569-0964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9259958367500000X
MA180430367500000X
CT003788367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL309102300Medicaid
FLARNP 9259958OtherFLA. ARNP# TAXONOMY FIELD
FL309102300Medicaid
FL309102300Medicaid