Provider Demographics
NPI:1407959380
Name:HARRELL, MARCUS EUGENE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:EUGENE
Last Name:HARRELL
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 1:101 W IRONWOOD DR STE 250
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-1415
Mailing Address - Country:US
Mailing Address - Phone:208-765-8585
Mailing Address - Fax:
Practice Address - Street 1:101 W IRONWOOD DR STE 250
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-1415
Practice Address - Country:US
Practice Address - Phone:208-765-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA-902A367500000X
TX625990367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX050889OtherCRNA LICENSE
TX89607UOtherBCBS
TX002958903Medicaid
ID1457939380Medicaid
TX625990OtherTEXAS STATE NURSE LICENSE
TXP00719258OtherRAILROAD