Provider Demographics
NPI:1336658889
Name:MARK, THORA C (NP-C)
Entity Type:Individual
Prefix:MS
First Name:THORA
Middle Name:C
Last Name:MARK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5152
Mailing Address - Street 2:
Mailing Address - City:MANGILAO
Mailing Address - State:GU
Mailing Address - Zip Code:96923-5152
Mailing Address - Country:US
Mailing Address - Phone:671-734-6275
Mailing Address - Fax:
Practice Address - Street 1:520 W SANTA MONICA AVE
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-5286
Practice Address - Country:US
Practice Address - Phone:671-635-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GURX0487163W00000X
GUNP0169363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse