Healthcare Provider Details

I. General information

NPI: 1174583561
Provider Name (Legal Business Name): MARLON J COOK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTH IH 35
PEARSALL TX
78061
US

IV. Provider business mailing address

PO BOX 506
SWEETWATER TX
79556-0506
US

V. Phone/Fax

Practice location:
  • Phone: 830-334-3617
  • Fax: 830-334-9803
Mailing address:
  • Phone: 830-334-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number501684
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: