Provider Demographics
NPI:1437266632
Name:EDWARDS, MARK ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:EDWARDS
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:PO BOX 1383
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-1383
Mailing Address - Country:US
Mailing Address - Phone:406-291-4032
Mailing Address - Fax:
Practice Address - Street 1:350 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2130
Practice Address - Country:US
Practice Address - Phone:406-293-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT32552367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93534Medicaid
NM93534Medicaid