Healthcare Provider Details

I. General information

NPI: 1194921973
Provider Name (Legal Business Name): MARK RICHARD MARTENS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 GREENWAY DR
DELANO MN
55328-4571
US

IV. Provider business mailing address

310 GREENWAY DR
DELANO MN
55328-4571
US

V. Phone/Fax

Practice location:
  • Phone: 763-229-5441
  • Fax:
Mailing address:
  • Phone: 763-229-5441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR162211-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: