Provider Demographics
NPI:1467091751
Name:COLALUCA, MARK JAMES (CNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAMES
Last Name:COLALUCA
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 MCKAY CT STE 100
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5786
Mailing Address - Country:US
Mailing Address - Phone:330-758-4399
Mailing Address - Fax:330-758-8995
Practice Address - Street 1:835 MCKAY CT STE 100
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5786
Practice Address - Country:US
Practice Address - Phone:330-758-4399
Practice Address - Fax:330-758-8995
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025827363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology