Provider Demographics
NPI:1447380258
Name:WILLIAMS, MARK EDWARD (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2160 N HIGHWAY A1A
Mailing Address - Street 2:UNIT 104
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2559
Mailing Address - Country:US
Mailing Address - Phone:321-725-5151
Mailing Address - Fax:321-725-5157
Practice Address - Street 1:1401 S APOLLO BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3179
Practice Address - Country:US
Practice Address - Phone:321-725-5151
Practice Address - Fax:321-725-5157
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9243193367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBCBS G2420OtherBCBS
FLBCBS G2420OtherBCBS
FLK4762Medicare PIN