Healthcare Provider Details

I. General information

NPI: 1528489184
Provider Name (Legal Business Name): MARK GORDON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2013
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-3742
US

IV. Provider business mailing address

425 LEWIS HARGETT CIR
LEXINGTON KY
40503-3590
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5956
  • Fax: 859-323-1080
Mailing address:
  • Phone: 859-268-1030
  • Fax: 859-269-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1121654
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3008454
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: