Active NPI
Shannan Rotruck, CRNA
- Registered Nurse
- Pearl Harbor, HI
National Provider Identifier
1255753455
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Nurse
- License
- 4704244122
- Practice address
- 480 Central Ave
Pearl Harbor, HI 96860-4908 - Phone
- (808) 474-4242
- NPI assigned
- Jan 8, 2014
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 4704244122 | MI | Primary |
Addresses
Primary practice location
480 Central Ave
Pearl Harbor, HI 96860-4908
Mailing address
3 Bayshore CT
Gaithersburg, MD 20878-1979
Phone (850) 449-9228
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4704244122 | MI | MD | Registered Nurse |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1389139200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1667347200000",
"number": "1255753455",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3 BAYSHORE CT",
"city": "GAITHERSBURG",
"state": "MD",
"postal_code": "208781979",
"telephone_number": "850-449-9228"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "480 CENTRAL AVE",
"city": "PEARL HARBOR",
"state": "HI",
"postal_code": "968604908",
"telephone_number": "808-474-4242"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROTRUCK",
"first_name": "SHANNAN",
"credential": "CRNA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2014-01-08",
"last_updated": "2022-11-02",
"certification_date": "2022-11-01",
"status": "A"
},
"taxonomies": [
{
"code": "163W00000X",
"taxonomy_group": "",
"desc": "Registered Nurse",
"state": "MI",
"license": "4704244122",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pearl Harbor, HI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.