Provider Demographics
NPI:1235378605
Name:WALLACE, SHANE K (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:K
Last Name:WALLACE
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 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-430-3500
Mailing Address - Fax:606-437-1033
Practice Address - Street 1:911 BYPASS RD BLDG A
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1689
Practice Address - Country:US
Practice Address - Phone:606-430-3500
Practice Address - Fax:606-437-1033
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001179608163W00000X
VA0024168171367500000X
TN33501367500000X
KY3008218367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235378605Medicaid
KY7100075570Medicaid
KY7100075570Medicaid