Provider Demographics
NPI:1447456132
Name:NUTI, BENJAMIN SHANE (CRNA)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:SHANE
Last Name:NUTI
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 1:914 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067
Mailing Address - Country:US
Mailing Address - Phone:530-926-6111
Mailing Address - Fax:530-926-0245
Practice Address - Street 1:914 PINE STREET
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067
Practice Address - Country:US
Practice Address - Phone:530-926-6111
Practice Address - Fax:530-926-0245
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3558367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA05502OtherWELLMARK BCBS
IAI20503Medicare PIN
IAP00438098Medicare PIN