Provider Demographics
NPI:1023048303
Name:CREASEY, MARK WADE (FNP-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WADE
Last Name:CREASEY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-2298
Mailing Address - Fax:
Practice Address - Street 1:6515 POPLAR AVE STE 106
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4878
Practice Address - Country:US
Practice Address - Phone:901-426-1090
Practice Address - Fax:901-426-1091
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34775363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily