Provider Demographics
NPI:1487959508
Name:MERRILL, SHANE B (CRNA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:B
Last Name:MERRILL
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 1:625 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2464
Mailing Address - Country:US
Mailing Address - Phone:360-501-3449
Mailing Address - Fax:
Practice Address - Street 1:625 9TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2464
Practice Address - Country:US
Practice Address - Phone:360-442-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSRA100020367500000X
WAAP60510081367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered