MEDICARE: MARK WADE CREASEY FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	34775	TN

General Provider Information

NPI Number	:	1023048303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK WADE CREASEY FNP-C

Provider Business Mailing Address
First Line	:	206 OXFORD RD
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-3115
Country	:	US
Telephone Number	:	662-534-2298
Fax Number	:

Provider Business Practice Location Address
First Line	:	6515 POPLAR AVE STE 106
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-4878
Country	:	US
Telephone Number	:	901-426-1090
Fax Number	:	901-426-1091

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	01/06/2025

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