Individual
SHANE K WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
911 BYPASS RD BLDG A, PIKEVILLE, KY 41501-1689
(606) 430-3500
(606) 437-1033
Mailing address
PO BOX 432, PIKEVILLE, KY 41502-0432
(606) 430-3500
(606) 437-1033
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
0001179608
VA
367500000X
Certified Registered Nurse Anesthetist
0024168171
VA
367500000X
Certified Registered Nurse Anesthetist
Primary
3008218
KY
367500000X
Certified Registered Nurse Anesthetist
33501
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1235378605
—
VA
05
—
7100075570
—
KY
Enumeration date
02/09/2009
Last updated
08/02/2023
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