Provider Demographics
NPI:1992138382
Name:MICHAEL, MARK REID (APRN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:REID
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-779-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6743505-4405282NC0060X
AZAP7279363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access