Provider Demographics
NPI:1114688769
Name:NAZARENO, MARK RAINIER (FNP)
Entity Type:Individual
Prefix:MR
First Name:MARK RAINIER
Middle Name:
Last Name:NAZARENO
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:NAZARENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1220 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-8972
Mailing Address - Country:US
Mailing Address - Phone:562-283-9267
Mailing Address - Fax:
Practice Address - Street 1:1220 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8972
Practice Address - Country:US
Practice Address - Phone:562-283-9267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019231363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily