Provider Demographics
NPI:1215375951
Name:CANDELARIA, TIMOTHY MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MARK
Last Name:CANDELARIA
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 1:1631 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4728
Mailing Address - Country:US
Mailing Address - Phone:505-983-3275
Mailing Address - Fax:
Practice Address - Street 1:1631 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4728
Practice Address - Country:US
Practice Address - Phone:505-323-7200
Practice Address - Fax:505-323-7206
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53366367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered