Provider Demographics
NPI:1700917242
Name:GREMILLION, MARK WILLIAM (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:GREMILLION
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:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:PLAUCHEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71362-0070
Mailing Address - Country:US
Mailing Address - Phone:318-253-8611
Mailing Address - Fax:
Practice Address - Street 1:4231 HIGHWAY 1192
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-4711
Practice Address - Country:US
Practice Address - Phone:318-253-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP01822367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1391298Medicaid
LA1391298Medicaid