Healthcare Provider Details

I. General information

NPI: 1144553132
Provider Name (Legal Business Name): MARK ANDREW WATERMAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 RADIO DR
SAINT PAUL MN
55125-2619
US

IV. Provider business mailing address

8170 33RD AVE S MAILSTOP 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax: 952-831-1626
Mailing address:
  • Phone: 952-883-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3295
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7366-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number96660
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number166438-30
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1668700
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: