Provider Demographics
NPI:1114445590
Name:STANDLEY, MARK AMBA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AMBA
Last Name:STANDLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 LAMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-4615
Mailing Address - Country:US
Mailing Address - Phone:806-676-1523
Mailing Address - Fax:
Practice Address - Street 1:111 W HOBBS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-1869
Practice Address - Country:US
Practice Address - Phone:575-623-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2018-0080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant