Provider Demographics
NPI:1124100714
Name:BRUCE, MARK D (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:BRUCE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14994 E LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:ARP
Mailing Address - State:TX
Mailing Address - Zip Code:75750-9781
Mailing Address - Country:US
Mailing Address - Phone:903-859-3403
Mailing Address - Fax:
Practice Address - Street 1:2901 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5128
Practice Address - Country:US
Practice Address - Phone:903-232-3606
Practice Address - Fax:903-593-4290
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX529621367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86187UOtherBCBS OF TEXAS
TXP00273951OtherPART B RAILROAD MEDICARE
TXP00273951OtherPART B RAILROAD MEDICARE