Provider Demographics
NPI:1053830018
Name:MONFASANI, MARK TIMOTHY (PMHNP-BC, AGNP-BC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TIMOTHY
Last Name:MONFASANI
Suffix:
Gender:M
Credentials:PMHNP-BC, AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MASTER DR STE 1
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-3052
Mailing Address - Country:US
Mailing Address - Phone:413-343-4357
Mailing Address - Fax:
Practice Address - Street 1:2 MASTER DR STE 1
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-3052
Practice Address - Country:US
Practice Address - Phone:413-343-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2310066363LA2200X, 363LP0808X
CA95007333363LA2200X, 363LP0808X
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
CA95007333OtherNURSE PRACTITIONER NUMBER
MARN2310066OtherNP LICENSE