Basic Information
| Provider Information | |||||||||
| NPI: | 1245571819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHANE | ||||||||
| FirstName: | JAYMA | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERRY | ||||||||
| OtherFirstName: | JAYMA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8600 N STATE ROUTE 91 | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096925393 | ||||||||
| FaxNumber: | 3096922538 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 N STATE ROUTE 91 | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616159541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096925393 | ||||||||
| FaxNumber: | 3096922538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2013 | ||||||||
| LastUpdateDate: | 10/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209.010281 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.