Provider Demographics
NPI:1629520127
Name:PARK, SHANE (CRNA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:PARK
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 1:11234 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:213-700-0178
Mailing Address - Fax:
Practice Address - Street 1:1551 E TANGERINE RD
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6213
Practice Address - Country:US
Practice Address - Phone:520-901-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000619367500000X
AZ233774367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered