Healthcare Provider Details

I. General information

NPI: 1780277616
Provider Name (Legal Business Name): MARCOS A. MAYORGA JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E DEVONSHIRE AVE
HEMET CA
92543-3083
US

IV. Provider business mailing address

31202 LINDEN FLOWER RD
WINCHESTER CA
92596-8228
US

V. Phone/Fax

Practice location:
  • Phone: 951-652-2811
  • Fax:
Mailing address:
  • Phone: 909-503-8346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number252990
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: