Provider Demographics
NPI:1912595810
Name:O'NEILL, SHANE CONNOR (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:CONNOR
Last Name:O'NEILL
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 1:130 HELLE BLVD APT 603
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:MI
Mailing Address - Zip Code:48131-8404
Mailing Address - Country:US
Mailing Address - Phone:248-504-7075
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311144367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered