Provider Demographics
NPI:1407829005
Name:SHANAHAN, JENNIFER G (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:SHANAHAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:G
Other - Last Name:LABADIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-142757-2367500000X
MN194367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN034592000Medicaid
IAENROLLEDMedicaid
WI44317000Medicaid
MN430071374OtherRAILROAD MEDICARE
MN034592000Medicaid