Provider Demographics
NPI:1649218611
Name:KRUITBOSCH, SHANE H (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:H
Last Name:KRUITBOSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18124 WEDGE PKWY # 933
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-8134
Mailing Address - Country:US
Mailing Address - Phone:775-742-0734
Mailing Address - Fax:
Practice Address - Street 1:4165 TWIN FALLS DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511
Practice Address - Country:US
Practice Address - Phone:775-348-1313
Practice Address - Fax:775-348-1798
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9827207L00000X
CAC134131207L00000X
ORMD207244207L00000X
NV10083207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2016072Medicaid
NV2016072Medicaid
NV36812Medicare PIN