Provider Demographics
NPI:1457739179
Name:WIITA, MARK (APRN, CNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WIITA
Suffix:
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E SUPERIOR ST STE L401
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2207
Mailing Address - Country:US
Mailing Address - Phone:218-249-7960
Mailing Address - Fax:218-249-7997
Practice Address - Street 1:1001 E SUPERIOR ST STE L401
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2207
Practice Address - Country:US
Practice Address - Phone:218-249-7960
Practice Address - Fax:218-249-7997
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR210059-7363LF0000X
MN3981363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily