Provider Demographics
NPI:1063634277
Name:FLORES, MARK A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:FLORES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 PROFESSIONAL WAY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-4404
Mailing Address - Country:US
Mailing Address - Phone:360-426-2500
Mailing Address - Fax:
Practice Address - Street 1:237 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-4404
Practice Address - Country:US
Practice Address - Phone:360-426-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005173363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8481137Medicaid
Q79596Medicare UPIN
WA8481137Medicaid