Provider Demographics
NPI:1851611016
Name:CARTER, JOHN MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:CARTER
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 1:8422 E SHEA BLVD
Mailing Address - Street 2:103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6661
Mailing Address - Country:US
Mailing Address - Phone:480-478-6620
Mailing Address - Fax:480-478-6628
Practice Address - Street 1:8422 E SHEA BLVD
Practice Address - Street 2:103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6661
Practice Address - Country:US
Practice Address - Phone:480-478-6620
Practice Address - Fax:480-478-6628
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN 02769163W00000X
PARN 590080163W00000X
CARN 650968163W00000X
CARN 357922163W00000X
AZCRNA 084670367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ528901Medicaid