Provider Demographics
NPI:1265438980
Name:SHEARER, JACK R (CRNA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:R
Last Name:SHEARER
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 1:262 DANNY THOMAS PL
Mailing Address - Street 2:MS 515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3006
Mailing Address - Fax:901-595-3842
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3006
Practice Address - Fax:901-595-3842
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN144583367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1472115Medicaid
TX174264501Medicaid
MS04132040Medicaid
ME422400000Medicaid
MI104694231Medicaid
MO919333104Medicaid
MT4307498Medicaid
SCQAN028Medicaid
VA010133181Medicaid
OK200055730AMedicaid
IN200522250AMedicaid
OH2524076Medicaid
KS9572Medicaid
AR157589001Medicaid
TN5440235Medicaid
VA010133181Medicaid