Provider Demographics
NPI:1699198747
Name:GOFORTH, MARK A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:A
Other - Last Name:GOFORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:14029 E. CAMINO GALANTE
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641
Mailing Address - Country:US
Mailing Address - Phone:520-904-7987
Mailing Address - Fax:
Practice Address - Street 1:14029 E CAMINO GALANTE
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-2067
Practice Address - Country:US
Practice Address - Phone:520-904-7987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily