Provider Demographics
NPI:1770641953
Name:COUCH, MARK EDWARD (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:COUCH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 UPPER RIVERDALE RD SE
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2635
Mailing Address - Country:US
Mailing Address - Phone:770-907-7222
Mailing Address - Fax:
Practice Address - Street 1:34 UPPER RIVERDALE RD SE
Practice Address - Street 2:SUITE 100A
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2635
Practice Address - Country:US
Practice Address - Phone:770-907-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN124073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ49146Medicare UPIN
GA50BBJPCMedicare ID - Type Unspecified