Provider Demographics
NPI:1326103490
Name:KELLOGG, MARK T (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:KELLOGG
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 1:1101 HOLLY CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1171
Mailing Address - Country:US
Mailing Address - Phone:573-747-1180
Mailing Address - Fax:
Practice Address - Street 1:1101 HOLLY CT
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1171
Practice Address - Country:US
Practice Address - Phone:573-631-5116
Practice Address - Fax:573-756-8288
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO154494261QA1903X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO914703533Medicaid