Provider Demographics
NPI:1396385662
Name:LIDASAN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LIDASAN
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 1:7070 KNIGHTS CT STE 1701
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5551
Mailing Address - Country:US
Mailing Address - Phone:983-293-3173
Mailing Address - Fax:832-281-1383
Practice Address - Street 1:7070 KNIGHTS CT STE 1701
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-5551
Practice Address - Country:US
Practice Address - Phone:346-595-3735
Practice Address - Fax:832-281-1383
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX144499363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health