Provider Demographics
NPI:1306015417
Name:VAN OVER, MARK L (FNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:VAN OVER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:L
Other - Last Name:VANOVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4589
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4589
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 17478363LF0000X
OR201500476NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNORTH BEND MEDICAL CENTER GROUP NPI
OR500712548Medicaid
ORR0000WFBTVOtherNORTH BEND MEDICAL CENTER GROUP MEDICARE
OR161133OtherNORTH BEND MEDICAL CENTER GROUP MEDICAID
OR1407812365OtherNORTH BEND MEDICAL CENTER GROUP NPI