Provider Demographics
NPI:1316120868
Name:TITCOMB, MARK B (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:TITCOMB
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 1:1860 VIRGINIA AVE STE 9
Mailing Address - Street 2:PO BOX 349
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-2355
Mailing Address - Country:US
Mailing Address - Phone:541-756-2070
Mailing Address - Fax:541-756-1999
Practice Address - Street 1:1775 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2125
Practice Address - Country:US
Practice Address - Phone:541-269-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274528Medicaid