Healthcare Provider Details

I. General information

NPI: 1124100714
Provider Name (Legal Business Name): MARK D BRUCE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 N 4TH ST
LONGVIEW TX
75605-5128
US

IV. Provider business mailing address

14994 E LAKE CIR
ARP TX
75750-9781
US

V. Phone/Fax

Practice location:
  • Phone: 903-232-3606
  • Fax: 903-593-4290
Mailing address:
  • Phone: 903-859-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number529621
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: