Basic Information
| Provider Information | |||||||||
| NPI: | 1881991586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOVALL | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 GREENWAY PLZ | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770460297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137981835 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1504 TAUB LOOP | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138732000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2011 | ||||||||
| LastUpdateDate: | 05/23/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 689527 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.