Provider Demographics
NPI:1194780148
Name:ALLEN, RICHARD MARK (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MARK
Last Name:ALLEN
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 1:162 CEDAR LANE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351
Mailing Address - Country:US
Mailing Address - Phone:936-967-4010
Mailing Address - Fax:
Practice Address - Street 1:2606 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1818
Practice Address - Country:US
Practice Address - Phone:361-949-4976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX237108367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85523UOtherBCBSTX
TX85523UOtherBCBSTX