Provider Demographics
NPI:1164784310
Name:PROCHNAU, MARK M (MSN, CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:PROCHNAU
Suffix:
Gender:M
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-571-6386
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201240512RN163W00000X
OR201260049CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse