Provider Demographics
NPI:1265435556
Name:SHANNON, TINA NANNETTE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:NANNETTE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:NANNETTE
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:311 SOUTHPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2471
Mailing Address - Country:US
Mailing Address - Phone:304-546-3081
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV54626367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV27005299700OtherWORKER'S COMP-MAAC
OH2624413Medicaid
WV270052997OtherTAX ID -MAAC
WV2601300000Medicaid
WVP00258571OtherMEDICARE
WV001713630OtherBCBS-MAAC