Provider Demographics
NPI:1902474893
Name:SHUMWAY, STETLER LADD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STETLER
Middle Name:LADD
Last Name:SHUMWAY
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 1:2801 N BLUE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-2012
Mailing Address - Country:US
Mailing Address - Phone:435-459-2616
Mailing Address - Fax:
Practice Address - Street 1:380 W 100 N
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535
Practice Address - Country:US
Practice Address - Phone:435-587-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC247971163W00000X
UT9124570-8901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse