Basic Information
| Provider Information | |||||||||
| NPI: | 1427345545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STROH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2011 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APN.0990919-CRNA | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 38124211 | 05 | CO | MEDICAID | C15283 | 01 | CO | RR MEDICARE | OTHER |