Healthcare Provider Details

I. General information

NPI: 1780144410
Provider Name (Legal Business Name): MARK ALAN MEDAKOVICH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ELM AND CARLTON STREETS
BUFFALO NY
14263-1104
US

IV. Provider business mailing address

16 KETCHUM PL
BUFFALO NY
14213-2661
US

V. Phone/Fax

Practice location:
  • Phone: 716-845-2300
  • Fax:
Mailing address:
  • Phone: 716-870-9108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number647277
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number647277
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: