Basic Information
| Provider Information | |||||||||
| NPI: | 1689801383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TROSCLAIR | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 SPRING FOREST RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276162880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198820795 | ||||||||
| FaxNumber: | 9198739821 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 HUFFMAN MILL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365387000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3006972 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 82125 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100190420 | 05 | KY | MEDICAID |