Provider Demographics
NPI:1023098548
Name:AGPOON, MARK (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AGPOON
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 1:3314 N 124TH ST W
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67223-6909
Mailing Address - Country:US
Mailing Address - Phone:316-722-8049
Mailing Address - Fax:316-722-8049
Practice Address - Street 1:3314 N 124TH ST W
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67223-6909
Practice Address - Country:US
Practice Address - Phone:316-722-8049
Practice Address - Fax:316-722-8049
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS55429367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200331110GMedicaid
KS110017038Medicare PIN
KS200331110GMedicaid