Provider Demographics
NPI:1891752101
Name:SKIDMORE, MARK VERLYN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VERLYN
Last Name:SKIDMORE
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 1:7463 E 8TH PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230
Mailing Address - Country:US
Mailing Address - Phone:720-216-0385
Mailing Address - Fax:
Practice Address - Street 1:300 E HAMPTON AVE
Practice Address - Street 2:#202
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2654
Practice Address - Country:US
Practice Address - Phone:303-789-1940
Practice Address - Fax:303-789-2132
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO161411367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO490668Medicare ID - Type Unspecified