Provider Demographics
NPI:1992791735
Name:SHIN, DONG H (CRNA)
Entity type:Individual
Prefix:
First Name:DONG
Middle Name:H
Last Name:SHIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 NOVUS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8237
Mailing Address - Country:US
Mailing Address - Phone:423-283-0776
Mailing Address - Fax:423-968-5697
Practice Address - Street 1:1009 NOVUS DR STE 2
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8237
Practice Address - Country:US
Practice Address - Phone:423-283-0776
Practice Address - Fax:423-968-5697
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000054267367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3607477Medicaid
TN3607470Medicare PIN