Provider Demographics
NPI:1447773478
Name:FOSSMEYER, MARCUS W (DNP, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:W
Last Name:FOSSMEYER
Suffix:
Gender:M
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 N CENTRAL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2639
Mailing Address - Country:US
Mailing Address - Phone:602-230-7373
Mailing Address - Fax:602-682-7455
Practice Address - Street 1:2204 S DOBSON RD STE 102
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6457
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:480-628-8577
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN175917163W00000X
AZAP10434363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid