Healthcare Provider Details

I. General information

NPI: 1801824875
Provider Name (Legal Business Name): MARK J POULIN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 E MCDOWELL RD
PHOENIX AZ
85008-7735
US

IV. Provider business mailing address

3003 N CENTRAL AVE SUITE 200
PHOENIX AZ
85012-2902
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-275-1355
Mailing address:
  • Phone: 602-685-6000
  • Fax: 602-302-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN108520
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP1737
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: