Provider Demographics
NPI:1750701009
Name:LARSON, SHANNAN NICOLE (CRNA)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:NICOLE
Last Name:LARSON
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:PO BOX 843032
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3032
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:913-381-0979
Practice Address - Street 1:404 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219
Practice Address - Country:US
Practice Address - Phone:641-628-6634
Practice Address - Fax:641-621-2458
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA133501207L00000X
IAD133501367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology