Provider Demographics
NPI:1801855713
Name:KRUMM, SHANNON JOSEPH (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JOSEPH
Last Name:KRUMM
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:PO BOX 1660
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-0660
Mailing Address - Country:US
Mailing Address - Phone:816-461-8288
Mailing Address - Fax:816-461-6586
Practice Address - Street 1:404 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1291
Practice Address - Country:US
Practice Address - Phone:641-628-6634
Practice Address - Fax:816-461-6586
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA103187367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0206516Medicaid
R30636Medicare UPIN
IA0206516Medicaid