Provider Demographics
NPI:1831282284
Name:MCSHANE, KEVIN (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MCSHANE
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 1:16 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-6211
Mailing Address - Country:US
Mailing Address - Phone:303-669-6401
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:617-636-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79915367500000X
MARN2268707367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07799158Medicaid
COF72516Medicare PIN