Provider Demographics
NPI:1528022993
Name:ODDEN, MARK G (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:G
Last Name:ODDEN
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 359
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-0359
Mailing Address - Country:US
Mailing Address - Phone:563-927-7457
Mailing Address - Fax:563-927-7518
Practice Address - Street 1:17893 224TH ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-8629
Practice Address - Country:US
Practice Address - Phone:563-927-6183
Practice Address - Fax:563-927-6183
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-074818367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26702OtherRMC BC/BS IOWA
IA43951OtherVINTON BC/BS IOWA
IA6274647Medicaid
IA1274647Medicaid
IA327467Medicaid
IA4274647Medicaid
IA47146OtherINDE BC/BS IOWA
IA35258OtherSUMNER BC/BS IOWA
IA35258OtherSUMNER BC/BS IOWA
IA47146OtherINDE BC/BS IOWA
IA1274647Medicaid
IAR03213Medicare UPIN
IA6274647Medicaid