Provider Demographics
NPI:1063986776
Name:SHELLEY, KIRK ROBERT JR (CRNA)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:ROBERT
Last Name:SHELLEY
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SETTLERS PT
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3235
Mailing Address - Country:US
Mailing Address - Phone:864-630-7431
Mailing Address - Fax:
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN282650163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse