Healthcare Provider Details

I. General information

NPI: 1538102249
Provider Name (Legal Business Name): MARK J MARTINEAU CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CERILLOS ROAD
SANTA FE NM
87505
US

IV. Provider business mailing address

7033 VUELTA VISTOSO
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-946-9557
  • Fax:
Mailing address:
  • Phone: 505-660-3156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN081644
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: