Healthcare Provider Details

I. General information

NPI: 1942296744
Provider Name (Legal Business Name): MARK A KOSSICK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 SAND HILL RD OFFICE 618
CANDLER NC
28715-8943
US

IV. Provider business mailing address

1459 SAND HILL RD OFFICE 618
CANDLER NC
28715-8943
US

V. Phone/Fax

Practice location:
  • Phone: 828-670-8810
  • Fax: 828-670-8816
Mailing address:
  • Phone: 828-670-8810
  • Fax: 828-670-8816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number036721
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number237443
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: