Basic Information
Provider Information
NPI: 1003140179
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BRIGHT
FirstName: SHAWN
MiddleName: D
NamePrefix:  
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 111 QUAIL RIDGE WAY
Address2:  
City: JONESBOROUGH
State: TN
PostalCode: 376597430
CountryCode: US
TelephoneNumber: 4232243460
FaxNumber: 4232243460
Practice Location
Address1: 2204 PAVILION DR
Address2: SUITE 108
City: KINGSPORT
State: TN
PostalCode: 376604657
CountryCode: US
TelephoneNumber: 4233926100
FaxNumber: 4233926159
Other Information
ProviderEnumerationDate: 09/23/2009
LastUpdateDate: 05/31/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000X82010TNY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

No ID Information.


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