Provider Demographics
NPI:1689691222
Name:MCNEALLY, SHAWN L (CRNA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:L
Last Name:MCNEALLY
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 1:1720 UNIVERSITY DR S
Mailing Address - Street 2:ROUTE 1707
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-234-1728
Mailing Address - Fax:701-234-1681
Practice Address - Street 1:2301 25TH ST S STE K
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6104
Practice Address - Country:US
Practice Address - Phone:701-234-1728
Practice Address - Fax:701-234-1681
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26995367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AMedicare UPIN