Provider Demographics
NPI:1821475849
Name:BLAKE, SHAWN C (CRNA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:C
Last Name:BLAKE
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 1:235 8TH AVE W
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-1062
Mailing Address - Country:US
Mailing Address - Phone:563-547-2101
Mailing Address - Fax:563-547-3448
Practice Address - Street 1:235 8TH AVE W
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1062
Practice Address - Country:US
Practice Address - Phone:563-547-2101
Practice Address - Fax:563-547-3448
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD116603363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner