Basic Information
Provider Information | |||||||||
NPI: | 1093734675 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERSPAMER | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 RIVER FRST | ||||||||
Address2: |   | ||||||||
City: | CASTROVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 780092715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8305383306 | ||||||||
FaxNumber: | 8305383307 | ||||||||
Practice Location | |||||||||
Address1: | 3100 AVENUE E | ||||||||
Address2: |   | ||||||||
City: | HONDO | ||||||||
State: | TX | ||||||||
PostalCode: | 788613534 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8304267700 | ||||||||
FaxNumber: | 8304267860 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 02/02/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 243606 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 86714U | 01 | TX | BCBSTX | OTHER | 84374U | 01 | TX | BCBSTX | OTHER | 088858805 | 05 | TX |   | MEDICAID |