Provider Demographics
NPI:1922390210
Name:SHAH, KETAN R (CRNA)
Entity type:Individual
Prefix:MR
First Name:KETAN
Middle Name:R
Last Name:SHAH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3200 TYRE NECK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3329
Mailing Address - Country:US
Mailing Address - Phone:757-399-7451
Mailing Address - Fax:757-399-1158
Practice Address - Street 1:3200 TYRE NECK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3329
Practice Address - Country:US
Practice Address - Phone:757-399-7451
Practice Address - Fax:757-399-1158
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9431447367500000X
VA0024169375367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered