Provider Demographics
NPI:1861477952
Name:VINSON, SHELLEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:L
Last Name:VINSON
Suffix:
Gender:F
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 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0938
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:3705 MEDICAL PKWY STE 570
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1024
Practice Address - Country:US
Practice Address - Phone:512-454-2554
Practice Address - Fax:512-454-2824
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX049691367500000X
TXAP109119367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109760202Medicaid
TX00C86MOtherBLUE CROSS BLUE SHIELD
TX109760202OtherSUPERIOR CHIP
TX430071711OtherMEDICARE RAILROAD
TXS72266Medicare UPIN
TX00C86MOtherBLUE CROSS BLUE SHIELD