Provider Demographics
NPI:1730171158
Name:ADAMS, MARK WATSON (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WATSON
Last Name:ADAMS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1315
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1315
Mailing Address - Country:US
Mailing Address - Phone:706-210-9990
Mailing Address - Fax:706-210-0771
Practice Address - Street 1:811 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5336
Practice Address - Country:US
Practice Address - Phone:903-927-6770
Practice Address - Fax:903-927-6377
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX250719367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89182CMedicare ID - Type Unspecified