Provider Demographics
NPI:1861865743
Name:DUNHAM, MARK (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DUNHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 GLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4851
Mailing Address - Country:US
Mailing Address - Phone:912-265-9006
Mailing Address - Fax:912-554-3636
Practice Address - Street 1:3231 GLYNN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4851
Practice Address - Country:US
Practice Address - Phone:912-265-9006
Practice Address - Fax:912-554-3636
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN252952363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner