Provider Demographics
NPI:1750463337
Name:BENTLEY, MARY SOLAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SOLAN
Last Name:BENTLEY
Suffix:
Gender:F
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 8027
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8027
Mailing Address - Country:US
Mailing Address - Phone:903-526-1068
Mailing Address - Fax:903-593-4290
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-526-1068
Practice Address - Fax:903-593-4290
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX574505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86185UOtherBCBS OF TEXAS
TXP00294866OtherPART B RAILROAD MEDICARE
TXP00294866OtherPART B RAILROAD MEDICARE