Provider Demographics
NPI:1477541779
Name:VANVIEGEN, MARK J (ENP/FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:VANVIEGEN
Suffix:
Gender:M
Credentials:ENP/FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 BAL HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-5205
Mailing Address - Country:US
Mailing Address - Phone:919-426-1756
Mailing Address - Fax:
Practice Address - Street 1:416 BAL HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-5205
Practice Address - Country:US
Practice Address - Phone:919-426-1756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNP3029682363LA2100X
NC149084363LF0000X
WI11846363LF0000X
NC005002286363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00398888OtherRAILROAD MEDICARE
SCNP0297Medicaid
S89213Medicare UPIN
FLE6172XMedicare ID - Type Unspecified
SCNP0297Medicaid