Provider Demographics
NPI:1225087505
Name:SHELLENBERGER, JOHN N (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:SHELLENBERGER
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:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080
Mailing Address - Country:US
Mailing Address - Phone:731-415-3389
Mailing Address - Fax:
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7828
Practice Address - Fax:315-470-5811
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300825367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400063952Medicare PIN
NYJ400090630Medicare PIN