Provider Demographics
NPI:1306021282
Name:MALLETT, JOHN SHANE (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SHANE
Last Name:MALLETT
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 1:751 BAYOU PINES EAST DR
Mailing Address - Street 2:SUITE L
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7196
Mailing Address - Country:US
Mailing Address - Phone:337-436-8700
Mailing Address - Fax:337-436-3008
Practice Address - Street 1:751 BAYOU PINES EAST DR
Practice Address - Street 2:SUITE L
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7196
Practice Address - Country:US
Practice Address - Phone:337-436-8700
Practice Address - Fax:337-436-3008
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN085277207L00000X
TXAP121182367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1035963Medicaid
LA1035963Medicaid