Provider Demographics
NPI:1720099542
Name:SHIMATA, MANARDIE FRANCIS (DNAP, CRNA)
Entity Type:Individual
Prefix:
First Name:MANARDIE
Middle Name:FRANCIS
Last Name:SHIMATA
Suffix:
Gender:M
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3773 CHERRY HILLS CIR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-8402
Mailing Address - Country:US
Mailing Address - Phone:801-786-9233
Mailing Address - Fax:
Practice Address - Street 1:3773 CHERRY HILLS CIR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-8402
Practice Address - Country:US
Practice Address - Phone:801-786-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO164348367500000X
WAAP30006270367500000X
UT277586-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT190246100OtherDEPT OF LABOR
UT219498OtherALTIUS
UTTPRA07902OtherMOLINA
CO49408844Medicaid
UT68295OtherPEHP
UT005780209Medicare ID - Type Unspecified
UT68295OtherPEHP
COCO307257Medicare PIN