Healthcare Provider Details

I. General information

NPI: 1235127960
Provider Name (Legal Business Name): ZENON MERCADO III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SHULT DR
COLUMBUS TX
78934-3016
US

IV. Provider business mailing address

1005 LAMPLIGHT
ALLEYTON TX
78935-2152
US

V. Phone/Fax

Practice location:
  • Phone: 979-253-0445
  • Fax:
Mailing address:
  • Phone: 979-256-7387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number618405
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: