Provider Demographics
NPI:1417987868
Name:NIENHUIS, MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:NIENHUIS
Suffix:
Gender:M
Credentials:PA
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 358
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-0358
Mailing Address - Country:US
Mailing Address - Phone:505-786-5291
Mailing Address - Fax:505-786-6440
Practice Address - Street 1:#10 PUEBLO PINTADO SCHOOL
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:505-786-5291
Practice Address - Fax:505-786-6440
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97702242Medicaid
NM8HBU41Medicare ID - Type Unspecified
NM97702242Medicaid