Provider Demographics
NPI:1013529155
Name:SKOUSEN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SKOUSEN
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 1:1745 W WESTERN DOVE DR
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-6185
Mailing Address - Country:US
Mailing Address - Phone:480-586-0035
Mailing Address - Fax:
Practice Address - Street 1:1745 W WESTERN DOVE DR
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-6185
Practice Address - Country:US
Practice Address - Phone:480-586-0035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ246528363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health