Provider Demographics
NPI:1942577085
Name:BASHFORD, MARK EVERETT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EVERETT
Last Name:BASHFORD
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 1:216 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3901
Mailing Address - Country:US
Mailing Address - Phone:516-741-0570
Mailing Address - Fax:516-741-8276
Practice Address - Street 1:216 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3901
Practice Address - Country:US
Practice Address - Phone:516-741-0570
Practice Address - Fax:516-741-8276
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY540595367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY540595OtherLICENSE