Provider Demographics
NPI:1730170275
Name:ANNA, MARK (FNPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ANNA
Suffix:
Gender:M
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N AVENUE F
Mailing Address - Street 2:
Mailing Address - City:DENVER CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79323-2741
Mailing Address - Country:US
Mailing Address - Phone:806-592-9501
Mailing Address - Fax:806-592-3052
Practice Address - Street 1:703 AVE G
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:TX
Practice Address - Zip Code:79355
Practice Address - Country:US
Practice Address - Phone:806-456-6365
Practice Address - Fax:806-456-2057
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX654183363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0075DJOtherBLUE CROSS/BLUE SHIELD
TX0082EVOtherBLUE CROSS/BLUE SHIELD
TX137227810Medicaid
TX063623501Medicaid
458810Medicare Oscar/Certification
458811Medicare Oscar/Certification