Provider Demographics
NPI:1407161235
Name:PRIOLA, MARK CHARLES (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CHARLES
Last Name:PRIOLA
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 CLEARWATER DR., STE B
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305
Mailing Address - Country:US
Mailing Address - Phone:928-778-0626
Mailing Address - Fax:888-289-2598
Practice Address - Street 1:3105 CLEARWATER DR
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7166
Practice Address - Country:US
Practice Address - Phone:928-778-0626
Practice Address - Fax:928-415-4292
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145588Medicare PIN
Z145588Medicare PIN
Z93317Medicare PIN