Provider Demographics
NPI:1427056571
Name:MAYES, MARK MONROE (FNP-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:MONROE
Last Name:MAYES
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 JOHNSON RIDGE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2443
Mailing Address - Country:US
Mailing Address - Phone:336-526-1977
Mailing Address - Fax:336-526-0061
Practice Address - Street 1:250 JOHNSON RIDGE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2443
Practice Address - Country:US
Practice Address - Phone:336-526-1977
Practice Address - Fax:336-526-0061
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-02-15
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NC200897363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000331Medicaid
NCS70588Medicare UPIN
NC2598714BMedicare ID - Type Unspecified