Basic Information
Provider Information | |||||||||
NPI: | 1760778088 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WERNER | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | B. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | II | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1245 S CEDAR CREST BLVD STE 301 | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181036258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104028896 | ||||||||
FaxNumber: | 6104029029 | ||||||||
Practice Location | |||||||||
Address1: | 1200 S CEDAR CREST BLVD | ||||||||
Address2: |   | ||||||||
City: | ALLENTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 181036202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104028896 | ||||||||
FaxNumber: | 6104029029 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2011 | ||||||||
LastUpdateDate: | 03/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN569068 | PA | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 087956 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1599789 | 01 | PA | GATEWAY | OTHER | P01067607 | 01 | PA | RAILROAD MEDICARE | OTHER | 2631278 | 01 | PA | HIGHMARK | OTHER | 3842461000 | 01 | PA | IBC | OTHER | 2631278 | 01 | PA | FIRST PRIORITY | OTHER | 9360690 | 01 | PA | AETNA | OTHER | 1027812880001 | 05 | PA |   | MEDICAID | 149542 | 01 | PA | GEISINTER | OTHER | 12254842 | 01 | PA | CAQH | OTHER | 50101421 | 01 | PA | CAPITAL ADVANTAGE | OTHER |