Provider Demographics
NPI:1487793402
Name:BAZAN, DEMARKO VICTOR (CRNA)
Entity type:Individual
Prefix:MR
First Name:DEMARKO
Middle Name:VICTOR
Last Name:BAZAN
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 1:15342 SW 36TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4700
Mailing Address - Country:US
Mailing Address - Phone:305-559-2549
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136
Practice Address - Country:US
Practice Address - Phone:305-585-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3203632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered