Healthcare Provider Details

I. General information

NPI: 1942571831
Provider Name (Legal Business Name): MARK CREEK R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 12 AND HWY 17
FT. DEFIANCE AZ
86504-4039
US

IV. Provider business mailing address

3388 E LOCKETT RD
FLAGSTAFF AZ
86004-4039
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number145267
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: