Provider Demographics
NPI:1225452162
Name:SHELLEY, JOSHUA MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MICHAEL
Last Name:SHELLEY
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 1:3307 HALLIDAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3307 HALLIDAY AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1211
Practice Address - Country:US
Practice Address - Phone:314-368-0286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005021478163W00000X
MO2014011359367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2005021478OtherMISSOUIR NURISING LICENSE