Healthcare Provider Details

I. General information

NPI: 1730171158
Provider Name (Legal Business Name): MARK WATSON ADAMS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S WASHINGTON AVE
MARSHALL TX
75670-5336
US

IV. Provider business mailing address

PO BOX 1315
MARSHALL TX
75671-1315
US

V. Phone/Fax

Practice location:
  • Phone: 903-927-6770
  • Fax: 903-927-6377
Mailing address:
  • Phone: 706-210-9990
  • Fax: 706-210-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number250719
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: