Provider Demographics
NPI:1225088396
Name:SHADBOLT, HARVEY R (CRNA)
Entity Type:Individual
Prefix:
First Name:HARVEY
Middle Name:R
Last Name:SHADBOLT
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 2656
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-2656
Mailing Address - Country:US
Mailing Address - Phone:806-355-9595
Mailing Address - Fax:806-353-1589
Practice Address - Street 1:1501 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1770
Practice Address - Country:US
Practice Address - Phone:806-354-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231247367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088863802Medicaid
GA430028516OtherRR MEDICARE
TX088863802Medicaid