Provider Demographics
NPI:1073682423
Name:BACKMAN, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BACKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 24TH ST
Mailing Address - Street 2:#100
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2592
Mailing Address - Country:US
Mailing Address - Phone:360-293-3101
Mailing Address - Fax:360-588-1041
Practice Address - Street 1:1213 24TH ST
Practice Address - Street 2:#100
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2592
Practice Address - Country:US
Practice Address - Phone:360-293-3101
Practice Address - Fax:360-588-1041
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1789205Medicaid
WA1789205Medicaid