Provider Demographics
NPI:1417926130
Name:GAUGHAN, SHAWN THOMAS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:THOMAS
Last Name:GAUGHAN
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 1:1544 SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2331
Mailing Address - Country:US
Mailing Address - Phone:651-646-3091
Mailing Address - Fax:651-646-3124
Practice Address - Street 1:1544 SHELDON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-2331
Practice Address - Country:US
Practice Address - Phone:651-646-3091
Practice Address - Fax:651-646-3124
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 139202-1367500000X
MARN223809367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN985190900Medicaid