Provider Demographics
NPI:1659367035
Name:ETHERIDGE, MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ETHERIDGE
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 1:5680 SHELBY LN
Mailing Address - Street 2:
Mailing Address - City:WILMER
Mailing Address - State:AL
Mailing Address - Zip Code:36587-6800
Mailing Address - Country:US
Mailing Address - Phone:251-645-2529
Mailing Address - Fax:251-645-2529
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-471-7035
Practice Address - Fax:251-471-7042
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-080454367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552967Medicaid
AL051552967Medicare ID - Type Unspecified
AL051552967Medicaid