Provider Demographics
NPI:1639538986
Name:HINDE, MARK RAYMOND
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RAYMOND
Last Name:HINDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 S VAL VISTA DR STE 122
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6401
Mailing Address - Country:US
Mailing Address - Phone:480-547-6957
Mailing Address - Fax:
Practice Address - Street 1:4406 E MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7910
Practice Address - Country:US
Practice Address - Phone:480-547-6957
Practice Address - Fax:602-603-5595
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10757363LF0000X
AZAP8419363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ244993Medicaid