Provider Demographics
NPI:1053863662
Name:KESTNER, MARK THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:KESTNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MANNING ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4422
Mailing Address - Country:US
Mailing Address - Phone:602-315-0423
Mailing Address - Fax:
Practice Address - Street 1:44 MANNING ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4422
Practice Address - Country:US
Practice Address - Phone:602-315-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-30
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant