Provider Demographics
NPI:1013997410
Name:SHANDERSKY, MICHAEL T (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:SHANDERSKY
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 1:4705 W QUAIL HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5126
Mailing Address - Country:US
Mailing Address - Phone:337-478-8837
Mailing Address - Fax:
Practice Address - Street 1:751 E BAYOU PINES DR
Practice Address - Street 2:SUITE L
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7196
Practice Address - Country:US
Practice Address - Phone:337-436-8700
Practice Address - Fax:337-433-5942
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69234207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1924121Medicaid
LA1924121Medicaid
LA5S670Medicare ID - Type Unspecified