MEDICARE: MR. MARK ROY KENT 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	AP10730	AZ

General Provider Information

NPI Number	:	1700399839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ROY KENT FNP-C

Provider Business Mailing Address
First Line	:	1343 N ALMA SCHOOL RD
Second Line	:	STE 160
City	:	CHANDLER
State	:	AZ
Zip	:	85224-5901
Country	:	US
Telephone Number	:	480-963-1853
Fax Number	:	480-963-1854

Provider Business Practice Location Address
First Line	:	3312 E DESERT MOON TRL
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-3352
Country	:	US
Telephone Number	:	520-390-2321
Fax Number	:

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

Provider Enumeration Date	:	11/11/2017
Last Update Date	:	01/22/2018

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