Provider Demographics
NPI:1326191636
Name:MARKHAM, GWEN M (CRNA)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:M
Last Name:MARKHAM
Suffix:
Gender:F
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 13749
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-3749
Mailing Address - Country:US
Mailing Address - Phone:855-447-2240
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:350 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2901
Practice Address - Country:US
Practice Address - Phone:815-993-1671
Practice Address - Fax:815-936-6971
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-286365163W00000X
IL209-003239367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL51835OtherAANA
ILL99593Medicare PIN
IL51835OtherAANA