Provider Demographics
NPI:1083671986
Name:BALLER, MARK RICHARD (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:BALLER
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 1:10102 BLUFFMONT LN
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5570
Mailing Address - Country:US
Mailing Address - Phone:303-799-6859
Mailing Address - Fax:
Practice Address - Street 1:10102 BLUFFMONT LN
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5570
Practice Address - Country:US
Practice Address - Phone:303-799-6859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX541986367500000X
CO175201367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77228219Medicaid
COC807013Medicare PIN