Basic Information
| Provider Information | |||||||||
| NPI: | 1588287585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIPE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 19TH ST | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234513304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575766357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 736 BATTLEFIELD BLVD N | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573126200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2020 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0024179341 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.