Provider Demographics
NPI:1033456728
Name:STOUT, MARK PATRICK (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PATRICK
Last Name:STOUT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:18503 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9149
Mailing Address - Country:US
Mailing Address - Phone:405-531-4273
Mailing Address - Fax:405-531-4274
Practice Address - Street 1:18503 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9149
Practice Address - Country:US
Practice Address - Phone:405-531-4273
Practice Address - Fax:405-531-4274
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant