Healthcare Provider Details

I. General information

NPI: 1003884859
Provider Name (Legal Business Name): MARK DAVID MURLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E 19TH ST
ROSWELL NM
88201-5151
US

IV. Provider business mailing address

PO BOX 3059
ROSWELL NM
88202-3059
US

V. Phone/Fax

Practice location:
  • Phone: 575-624-2095
  • Fax:
Mailing address:
  • Phone: 575-624-2095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR40378
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: