Provider Demographics
NPI:1700124617
Name:MARK, GILDA (APRN)
Entity Type:Individual
Prefix:
First Name:GILDA
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:
Practice Address - Street 1:700 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1842
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:970-399-8037
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY28563.1212363LP0808X
COAPN.0996360-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105726000Medicaid