Healthcare Provider Details

I. General information

NPI: 1285661686
Provider Name (Legal Business Name): MARCUS ALAN GARDINER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10053 SINGER LAKE RD
BARODA MI
49101-9713
US

IV. Provider business mailing address

10053 SINGER LAKE RD
BARODA MI
49101-9713
US

V. Phone/Fax

Practice location:
  • Phone: 231-225-5216
  • Fax:
Mailing address:
  • Phone: 231-225-5216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704197009
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: