Provider Demographics
NPI:1124001409
Name:WHEELER, MARK A (PA-C, AA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WHEELER
Suffix:
Gender:M
Credentials:PA-C, AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 IRVING ST NW
Mailing Address - Street 2:ROOM G-226
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-3017
Mailing Address - Country:US
Mailing Address - Phone:202-877-7504
Mailing Address - Fax:202-877-5075
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:ROOM G-226
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-3017
Practice Address - Country:US
Practice Address - Phone:202-877-7504
Practice Address - Fax:202-877-5075
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1981363AS0400X
DCAA000026367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ374405Medicaid
AZ970004191OtherRAILROAD MEDICARE
AZ86080015085260A056OtherTRIWEST
AZ970004191OtherRAILROAD MEDICARE
AZ374405Medicaid