Provider Demographics
NPI:1083632160
Name:GUILZON, MARK DAVID (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:GUILZON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR STE 306
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9350
Mailing Address - Country:US
Mailing Address - Phone:570-522-4110
Mailing Address - Fax:570-768-3911
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9350
Practice Address - Country:US
Practice Address - Phone:570-522-2640
Practice Address - Fax:570-768-3921
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059673363AS0400X, 363A00000X
NY004445363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426006845OtherFIDELIS CARE
NY000405428003OtherBLUE SHIELD
NY040426006845OtherFIDELIS CARE
NYR74801Medicare UPIN