Healthcare Provider Details

I. General information

NPI: 1215337993
Provider Name (Legal Business Name): MARK DWAINE ALLRED CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 PINE ST
ABILENE TX
79601-2432
US

IV. Provider business mailing address

PO BOX 1198
ABILENE TX
79604-1198
US

V. Phone/Fax

Practice location:
  • Phone: 325-670-4220
  • Fax: 325-670-4040
Mailing address:
  • Phone: 325-670-4372
  • Fax: 325-670-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number868740
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: