MEDICARE: MR. MARK NEAL GORMAN CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	650033	TX

General Provider Information

NPI Number	:	1831192343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK NEAL GORMAN CRNA

Provider Business Mailing Address
First Line	:	PO BOX 129
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-0129
Country	:	US
Telephone Number	:	979-733-6394
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 BROADWAY ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-5301
Country	:	US
Telephone Number	:	361-552-3505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	01/25/2011

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