Provider Demographics
NPI:1326256363
Name:GUNDERSON, SHANIKA H (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SHANIKA
Middle Name:H
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANIKA
Other - Middle Name:H
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:13523 BARRETT PARKWAY DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3802
Mailing Address - Country:US
Mailing Address - Phone:314-775-2816
Mailing Address - Fax:314-775-2821
Practice Address - Street 1:2345 DOUGHERTY FERRY RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122
Practice Address - Country:US
Practice Address - Phone:314-821-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001003222367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO914462007Medicaid
MO836280276Medicare PIN