Provider Demographics
NPI:1013275502
Name:RETZ, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1486 73 1/2 AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:SUITE 250
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5850
Practice Address - Country:US
Practice Address - Phone:763-398-0124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN090396367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered