Provider Demographics
NPI:1164640926
Name:FALTYS, SHANE D (CRNA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:D
Last Name:FALTYS
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 1:12747 FOXWOOD PT
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-7746
Mailing Address - Country:US
Mailing Address - Phone:573-778-3870
Mailing Address - Fax:
Practice Address - Street 1:2620 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3396
Practice Address - Country:US
Practice Address - Phone:573-718-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004031200367500000X
IAD-102109367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered