Provider Demographics
NPI:1588641229
Name:MCCLANAHAN, MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCCLANAHAN
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 411
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48805-0411
Mailing Address - Country:US
Mailing Address - Phone:517-797-4476
Mailing Address - Fax:517-797-4478
Practice Address - Street 1:3271 W CARLETON RD
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9458
Practice Address - Country:US
Practice Address - Phone:517-797-4476
Practice Address - Fax:517-797-4478
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470212204367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704212204OtherLICENSE
MIMM212204OtherBLUE CROSS OF MI
MIMM212204OtherBLUE CROSS OF MI
MI0A36076Medicare PIN
MI430080356Medicare ID - Type UnspecifiedRAILROAD MEDICARE