Provider Demographics
NPI:1790791572
Name:VERHAGEN, MARK A (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:VERHAGEN
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 1:2368 VICTORY PKWY
Mailing Address - Street 2:SUIE 501
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2859
Mailing Address - Country:US
Mailing Address - Phone:513-872-7388
Mailing Address - Fax:513-872-7385
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-872-7388
Practice Address - Fax:513-872-7385
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-182476367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74005745Medicaid
OH0808988Medicaid
KY74005745Medicaid