Provider Demographics
NPI:1841906005
Name:FANKHAUSER, MARK ELIJAH (APRN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ELIJAH
Last Name:FANKHAUSER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 CROSSPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-1803
Mailing Address - Country:US
Mailing Address - Phone:956-603-1555
Mailing Address - Fax:956-800-6369
Practice Address - Street 1:4113 CROSSPOINT BLVD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1803
Practice Address - Country:US
Practice Address - Phone:956-603-1555
Practice Address - Fax:956-800-6369
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX934497163W00000X
TX1110869363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty