Provider Demographics
NPI:1548548506
Name:CLUCAS, SHALA DEANNE (CRNA)
Entity type:Individual
Prefix:
First Name:SHALA
Middle Name:DEANNE
Last Name:CLUCAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHALA
Other - Middle Name:DEANNE
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-715-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:6606 LBJ FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX723566163W00000X
CA751989163W00000X
TX88765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287409103Medicaid
TX8331UGOtherBCBS
TX362855YK6UMedicare PIN
TXP01013171OtherRAILROAD
TX287409102Medicaid