Provider Demographics
NPI:1780451765
Name:RANGEL, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RANGEL
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 1:7734 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7816
Mailing Address - Country:US
Mailing Address - Phone:602-569-3999
Mailing Address - Fax:
Practice Address - Street 1:7734 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7816
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant