Provider Demographics
NPI:1073823365
Name:ENZERRA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ENZERRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-3336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 WITMER RD
Practice Address - Street 2:SUITE 220
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2251
Practice Address - Country:US
Practice Address - Phone:215-442-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant