Provider Demographics
NPI:1922077940
Name:MARKS, MICHAEL BRADLEY (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRADLEY
Last Name:MARKS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3280A HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5250
Practice Address - Country:US
Practice Address - Phone:910-937-7200
Practice Address - Fax:910-937-7061
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201201363LF0000X, 363L00000X
KY3012624363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000339Medicaid
NC2806080CMedicare ID - Type Unspecified
P56796Medicare UPIN