Basic Information
| Provider Information | |||||||||
| NPI: | 1508950064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COMBS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1189 BANDERA DRIVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349959956 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 NORTH EAST AVE | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177884963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704178623 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 037212 | 01 | MI | CRNA/AANA | OTHER |