Provider Demographics
NPI:1386829281
Name:FANNING, MARK ALLEN (SA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:FANNING
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 GLENNWOOD
Mailing Address - Street 2:P.O. BOX 3129
Mailing Address - City:GLENN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043
Mailing Address - Country:US
Mailing Address - Phone:254-897-1445
Mailing Address - Fax:
Practice Address - Street 1:408 GLENNWOOD
Practice Address - Street 2:
Practice Address - City:GLENN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043
Practice Address - Country:US
Practice Address - Phone:254-897-1445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05-144246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist