Provider Demographics
NPI:1598193989
Name:HALL, MARK (PMHNP, NPP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:PMHNP, NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BROADWAY STE 1108
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3450
Mailing Address - Country:US
Mailing Address - Phone:646-500-8627
Mailing Address - Fax:646-863-1427
Practice Address - Street 1:16 MADISON SQ W STE 1108
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1629
Practice Address - Country:US
Practice Address - Phone:646-500-8627
Practice Address - Fax:646-863-1427
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013941363LA2200X
NY307355363LA2200X
PASP013252363LP0808X
NY401869363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102964985Medicaid
PA370182Medicare PIN