Healthcare Provider Details

I. General information

NPI: 1285462093
Provider Name (Legal Business Name): MARCO PAUL JOSEPH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

8323 N PALMYRA RD
CANFIELD OH
44406-9790
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2000
  • Fax:
Mailing address:
  • Phone: 330-774-8334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4056969
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: