Provider Demographics
NPI:1881152783
Name:ISON, MARK ANTHONY BERGONIA (CRNP- PMH)
Entity type:Individual
Prefix:MR
First Name:MARK ANTHONY
Middle Name:BERGONIA
Last Name:ISON
Suffix:
Gender:M
Credentials:CRNP- PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1501 SULGRAVE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1501 SULGRAVE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3650
Practice Address - Country:US
Practice Address - Phone:443-708-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-09
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR181848363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health