Provider Demographics
NPI:1982909610
Name:PELANDA, SHANE LAWRENCE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:LAWRENCE
Last Name:PELANDA
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 1:1044 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1006
Mailing Address - Country:US
Mailing Address - Phone:330-480-3658
Mailing Address - Fax:330-480-3439
Practice Address - Street 1:4135 BOARDMAN CANFIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9803
Practice Address - Country:US
Practice Address - Phone:330-286-5330
Practice Address - Fax:330-286-5396
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-12110-NA367500000X
OHNA-12110367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
12241994OtherCAQH
OH3128930Medicaid
OH000000761030OtherANTHEM BCBS
OHH088220OtherMEDICARE PTAN
OHP01135540OtherMEDICARE RAILROAD