Provider Demographics
NPI:1801824875
Name:POULIN, MARK J (NP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:J
Last Name:POULIN
Suffix:
Gender:M
Credentials:NP
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Mailing Address - Street 1:3003 N CENTRAL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2902
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:4909 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-7735
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:602-275-1355
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZRN108520363LP0808X
AZAP1737363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816233Medicaid
Q41575Medicare UPIN
AZZ170888Medicare PIN