1821087685 NPI number — SHAYNE HAUGLUM CRNA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821087685 NPI number — SHAYNE HAUGLUM CRNA

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HAUGLUM

Provider First Name:

SHAYNE

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

CRNA

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1821087685

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/19/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

1611 NW 12TH AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

MIAMI

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33136-1005

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

305-585-6586

Provider Business Mailing Address Fax Number:

305-585-5830

Provider First Line Business Practice Location Address:

3073 WHITE MOUNTAIN HWY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

NORTH CONWAY

Provider Business Practice Location Address State Name:

NH

Provider Business Practice Location Address Postal Code:

03860-5111

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

603-356-5461

Provider Business Practice Location Address Fax Number:

603-356-7651

Provider Enumeration Date:

10/14/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 367500000X , with the licence number:  048592311 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 367500000X , with the licence number: APRN9336042 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 010732448 . This is a "TRICARE WHITE MTN ANESTH." identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: NI1211 . This is a "ACS INDIVIDUAL" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: NI1207 . This is a "ACS WHITE MTN ANESTHESIA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: 276054 . This is a "HARVARD INDIVIDUAL" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: 40Y003831NH01 . This is a "ANTHEM INDIVIDUAL" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: 693984 . This is a "TUFTS INDIVIDUAL" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
• Identifier: 135830000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
• Identifier: 30342370 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
• Identifier: 237640099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
• Identifier: 50Y152300MA01 . This is a "ANTHEM WHITE MTN ANESTH." identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".