Healthcare Provider Details

I. General information

NPI: 1568733137
Provider Name (Legal Business Name): MARK TODD WRIGHT MN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901-7831
US

IV. Provider business mailing address

4988 ROBINHOOD LN
LAKESIDE AZ
85929-5119
US

V. Phone/Fax

Practice location:
  • Phone: 512-925-7978
  • Fax:
Mailing address:
  • Phone: 512-925-7978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP125093
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1500
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: