Basic Information
Provider Information | |||||||||
NPI: | 1629455258 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEW | ||||||||
FirstName: | WILLARD | ||||||||
MiddleName: | JEFFREY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 249 FAIRWAY LN | ||||||||
Address2: |   | ||||||||
City: | WILKESBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 286978543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5612712476 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1370 W D ST | ||||||||
Address2: |   | ||||||||
City: | NORTH WILKESBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 286593506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3366518100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2015 | ||||||||
LastUpdateDate: | 11/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 275190 | NC | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 367500000X | 275190 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.