Provider Demographics
NPI:1346608726
Name:FONSECA, MARK ALEXANDER (MSN AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXANDER
Last Name:FONSECA
Suffix:
Gender:M
Credentials:MSN AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SW 134TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-1177
Mailing Address - Country:US
Mailing Address - Phone:786-493-6556
Mailing Address - Fax:
Practice Address - Street 1:51 SW 134TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1177
Practice Address - Country:US
Practice Address - Phone:786-493-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9309582363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology