Provider Demographics
NPI:1982095444
Name:DOUGHTY, MARK WILLIAM (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:DOUGHTY
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 KEMPTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-2776
Mailing Address - Country:US
Mailing Address - Phone:907-244-3694
Mailing Address - Fax:
Practice Address - Street 1:4050 LAKE OTIS PKWY STE 210
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5221
Practice Address - Country:US
Practice Address - Phone:907-244-3694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily