Healthcare Provider Details

I. General information

NPI: 1083671986
Provider Name (Legal Business Name): MARK RICHARD BALLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10102 BLUFFMONT LN
LONE TREE CO
80124-5570
US

IV. Provider business mailing address

10102 BLUFFMONT LN
LONE TREE CO
80124-5570
US

V. Phone/Fax

Practice location:
  • Phone: 303-799-6859
  • Fax:
Mailing address:
  • Phone: 303-799-6859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number541986
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number175201
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: