MEDICARE: MARK LIDASAN

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	144499	TX

General Provider Information

NPI Number	:	1396385662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK LIDASAN

Provider Business Mailing Address
First Line	:	7070 KNIGHTS CT STE 1701
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-5551
Country	:	US
Telephone Number	:	983-293-3173
Fax Number	:	832-281-1383

Provider Business Practice Location Address
First Line	:	7070 KNIGHTS CT STE 1701
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-5551
Country	:	US
Telephone Number	:	346-595-3735
Fax Number	:	832-281-1383

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

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	04/03/2025

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