Healthcare Provider Details

I. General information

NPI: 1134691710
Provider Name (Legal Business Name): MARK HARRIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N TRIUMPH BLVD
LEHI UT
84043-4999
US

IV. Provider business mailing address

1274 W BRIDALWOOD LOOP
LEHI UT
84043-4908
US

V. Phone/Fax

Practice location:
  • Phone: 385-345-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8760841-3102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8760841-4406
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8760841-8901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: