Provider Demographics
NPI:1093833576
Name:ATHANS, MARK EDWARD (LSA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:ATHANS
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11822 FM 2432 RD
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-5912
Mailing Address - Country:US
Mailing Address - Phone:832-581-6369
Mailing Address - Fax:713-779-9862
Practice Address - Street 1:11822 FM 2432 RD
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378-5912
Practice Address - Country:US
Practice Address - Phone:832-581-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00029246ZS0410X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0004JROtherBCBS PROVIDER NUMBER