Healthcare Provider Details

I. General information

NPI: 1619897592
Provider Name (Legal Business Name): MARK RAYMOND FASSETT JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 E CEDAR AVE
GLADWIN MI
48624-2215
US

IV. Provider business mailing address

4790 WILDWOOD DR
HARRISON MI
48625-9650
US

V. Phone/Fax

Practice location:
  • Phone: 989-426-9295
  • Fax:
Mailing address:
  • Phone: 989-387-7698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704392567
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: