Provider Demographics
NPI:1407141443
Name:BENNETT, JOHN MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:BENNETT
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 1:6010 W AMARILLO BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1990
Mailing Address - Country:US
Mailing Address - Phone:506-355-7903
Mailing Address - Fax:
Practice Address - Street 1:6010 W AMARILLO BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1990
Practice Address - Country:US
Practice Address - Phone:806-355-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS557038367500000X
KS14100305061390200000X, 163W00000X
TXAP123261367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200740430AMedicaid
KS110017067Medicare PIN