Provider Demographics
NPI:1730206236
Name:GANSEN, SHAUNA (CRNA)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:GANSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 4TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164-1890
Mailing Address - Country:US
Mailing Address - Phone:507-825-5700
Mailing Address - Fax:507-825-6106
Practice Address - Street 1:916 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:PIPESTONE
Practice Address - State:MN
Practice Address - Zip Code:56164-1890
Practice Address - Country:US
Practice Address - Phone:507-825-5700
Practice Address - Fax:507-825-6106
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR030241367500000X
MNR229714-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS102141Medicare PIN