Basic Information
Provider Information | |||||||||
NPI: | 1851484489 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHURTLIFF | ||||||||
FirstName: | MAX | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3618 W 6000 S | ||||||||
Address2: |   | ||||||||
City: | ROY | ||||||||
State: | UT | ||||||||
PostalCode: | 84067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019939527 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3580 W 9000 S | ||||||||
Address2: |   | ||||||||
City: | WEST JORDAN | ||||||||
State: | UT | ||||||||
PostalCode: | 84070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019939527 | ||||||||
FaxNumber: | 8017335872 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 212191-4406 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 102600 | 01 | UT | GEM | OTHER | 293654 | 01 | UT | DMBA | OTHER | 39005 | 01 | UT | PEHP | OTHER | 870542403 84121 A003 | 01 | UT | TRICARE | OTHER | PR00993 | 01 | UT | MOLINA | OTHER | QMXAF01875 | 01 | UT | ALTIUS | OTHER | 107001189102 | 01 | UT | IHC | OTHER | 870542403SH1 | 01 | UT | EDUCATORS MUTUAL | OTHER |