Provider Demographics
NPI:1306163258
Name:DEPAS, MARVIN CABILANGAN (FNP)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:CABILANGAN
Last Name:DEPAS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-233-5110
Mailing Address - Fax:928-774-6687
Practice Address - Street 1:625 N. 13TH WEST
Practice Address - Street 2:NORTH COUNTRY HEALTHCARE, ST JOHNS
Practice Address - City:SAINT JOHNS
Practice Address - State:AZ
Practice Address - Zip Code:85936
Practice Address - Country:US
Practice Address - Phone:928-337-3705
Practice Address - Fax:928-337-3780
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ516484Medicaid