Basic Information
Provider Information
NPI: 1003148032
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KENTERA
FirstName: SHANNON
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1800 HARRISON ST
Address2: 7TH FLOOR
City: OAKLAND
State: CA
PostalCode: 946123466
CountryCode: US
TelephoneNumber: 5106256262
FaxNumber:  
Practice Location
Address1: 6600 BRUCEVILLE RD
Address2:  
City: SACRAMENTO
State: CA
PostalCode: 958234671
CountryCode: US
TelephoneNumber: 9166887254
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/01/2010
LastUpdateDate: 02/01/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000X3878CAY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

No ID Information.


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