Provider Demographics
NPI:1497542773
Name:CVENGROS-EDENS, MARK WILLIAM (APRN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:CVENGROS-EDENS
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:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:747 S 8TH ST STE C
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4884
Practice Address - Country:US
Practice Address - Phone:770-228-1767
Practice Address - Fax:770-228-7562
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193193363LF0000X
GARN296180363L00000X
GA296180163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse