Provider Demographics
NPI:1780129858
Name:FRISSE, MARK EDWIN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWIN
Last Name:FRISSE
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 1:3707 WIMBLEDON RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-1819
Mailing Address - Country:US
Mailing Address - Phone:615-720-7761
Mailing Address - Fax:615-936-0102
Practice Address - Street 1:3707 WIMBLEDON RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-1819
Practice Address - Country:US
Practice Address - Phone:615-720-7761
Practice Address - Fax:615-936-0102
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3A00207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOR3A00OtherSTATE LICENSURE