Healthcare Provider Details

I. General information

NPI: 1316162662
Provider Name (Legal Business Name): MARK A COVEC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 DOYLE PARK DR STE G04
SANTA ROSA CA
95405-4559
US

IV. Provider business mailing address

500 DOYLE PARK DR STE G04
SANTA ROSA CA
95405-4559
US

V. Phone/Fax

Practice location:
  • Phone: 707-573-8984
  • Fax: 707-573-0982
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF430331-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95001902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: