Provider Demographics
NPI:1124085600
Name:KROLL, SHAWN E (CRNA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:E
Last Name:KROLL
Suffix:
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 1:8990 SPRINGBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5884
Mailing Address - Country:US
Mailing Address - Phone:763-398-1162
Mailing Address - Fax:763-398-0124
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5850
Practice Address - Country:US
Practice Address - Phone:763-398-1162
Practice Address - Fax:763-398-0124
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 139446-9367500000X
IL209006983367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN978133100Medicaid
MN246P8KROtherBCBSMN
MN430005373Medicare PIN