Healthcare Provider Details

I. General information

NPI: 1427056571
Provider Name (Legal Business Name): MARK MONROE MAYES FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

250 JOHNSON RIDGE MEDICAL PARK
ELKIN NC
28621-2443
US

IV. Provider business mailing address

250 JOHNSON RIDGE MEDICAL PARK
ELKIN NC
28621-2443
US

V. Phone/Fax

Practice location:
  • Phone: 336-526-1977
  • Fax: 336-526-0061
Mailing address:
  • Phone: 336-526-1977
  • Fax: 336-526-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200897
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: