Provider Demographics
NPI:1659561470
Name:SHAW, JERRELL WAYNE (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRELL
Middle Name:WAYNE
Last Name:SHAW
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 1:3500 INTERSTATE 30
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2651
Mailing Address - Country:US
Mailing Address - Phone:972-681-7246
Mailing Address - Fax:972-681-8946
Practice Address - Street 1:3500 INTERSTATE 30 STE B240
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2685
Practice Address - Country:US
Practice Address - Phone:972-681-7246
Practice Address - Fax:972-681-8946
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX578398367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00413WMedicaid