Provider Demographics
NPI:1437241247
Name:SHANNON, BYRON RUSSELL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:BYRON
Middle Name:RUSSELL
Last Name:SHANNON
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 1:201 N STEWART ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1323
Mailing Address - Country:US
Mailing Address - Phone:608-647-6522
Mailing Address - Fax:608-647-8010
Practice Address - Street 1:333 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1914
Practice Address - Country:US
Practice Address - Phone:608-647-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46278-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4328950Medicaid
WI21577Medicare ID - Type Unspecified
R80265Medicare UPIN