Provider Demographics
NPI:1114145174
Name:RESTAD, MARK VICTOR (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:VICTOR
Last Name:RESTAD
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:11472 KENAI SPUR HWY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7756
Mailing Address - Country:US
Mailing Address - Phone:907-283-6030
Mailing Address - Fax:907-283-3194
Practice Address - Street 1:11472 KENAI SPUR HWY
Practice Address - Street 2:SUITE #2
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7756
Practice Address - Country:US
Practice Address - Phone:907-283-6030
Practice Address - Fax:907-283-3194
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2014-05-21
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Provider Licenses
StateLicense IDTaxonomies
AK344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKS16168Medicare UPIN