Provider Demographics
NPI:1295815611
Name:RICCIONI, MARK (CPNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RICCIONI
Suffix:
Gender:M
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2316
Mailing Address - Country:US
Mailing Address - Phone:832-824-6230
Mailing Address - Fax:832-825-6229
Practice Address - Street 1:6701 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2316
Practice Address - Country:US
Practice Address - Phone:832-824-6230
Practice Address - Fax:832-825-6229
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX707537363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169784901Medicaid
TX8C9998Medicare PIN
TX169784901Medicaid
TX8L6670Medicare PIN