Healthcare Provider Details

I. General information

NPI: 1205566304
Provider Name (Legal Business Name): MARK ANDERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MDG OPC 41 BOX 15
APO AE
09461
US

IV. Provider business mailing address

48 MDG OPC 41 BOX 15
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 712-363-0889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: