Provider Demographics
NPI:1396742946
Name:SEIFERT, SHANNON (CRNA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SEIFERT
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 1:7108 SANDY SPRING RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5310
Mailing Address - Country:US
Mailing Address - Phone:240-603-7987
Mailing Address - Fax:
Practice Address - Street 1:201 E UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2829
Practice Address - Country:US
Practice Address - Phone:410-455-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR145654367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD454MK569OtherTRAILBLAZER
MD406930700Medicaid