Healthcare Provider Details

I. General information

NPI: 1306575014
Provider Name (Legal Business Name): MARK TIMOTHY CRESAP DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CLINCH AVE
KNOXVILLE TN
37916-2307
US

IV. Provider business mailing address

7357 LUCKY CLOVER LN
KNOXVILLE TN
37931-2236
US

V. Phone/Fax

Practice location:
  • Phone: 865-541-1111
  • Fax:
Mailing address:
  • Phone: 423-215-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0000198584
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number32505
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: