Provider Demographics
NPI:1689736266
Name:MENDENHALL, RICHARD MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:MENDENHALL
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:ABC
Mailing Address - Street 2:
Mailing Address - City:ABC
Mailing Address - State:NV
Mailing Address - Zip Code:12345-1030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39400 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2310
Practice Address - Country:US
Practice Address - Phone:510-784-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA989367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3085710OtherMEDICAL
CAQ15014Medicare UPIN