Provider Demographics
NPI:1205875911
Name:GRUBER, MARK A (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GRUBER
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 1:404 EASTLEY CT APT 2
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-6411
Mailing Address - Country:US
Mailing Address - Phone:803-479-2372
Mailing Address - Fax:
Practice Address - Street 1:3500 ARENDELL ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2901
Practice Address - Country:US
Practice Address - Phone:252-499-6000
Practice Address - Fax:252-808-6938
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN197129L367500000X
WV74148367500000X
NC157903367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053355Medicaid
ND8053355Medicaid
PA165554472OtherTRICARE
NC2606469AMedicare PIN
PA049394PKFMedicare ID - Type Unspecified