Provider Demographics
NPI:1831475649
Name:WASHAM, MARK A (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WASHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 11024
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-0375
Mailing Address - Fax:513-803-1124
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 11024
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-0375
Practice Address - Fax:513-803-1124
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA12015-NP363LF0000X
OHAPRN.CNP.12015363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily