Provider Demographics
NPI:1144277997
Name:PIRAK, MARK E (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:PIRAK
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 1:500 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4008
Mailing Address - Country:US
Mailing Address - Phone:406-728-2539
Mailing Address - Fax:406-329-5663
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-728-2539
Practice Address - Fax:406-329-5663
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003222363A00000X
MT70432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10003222OtherSTATE LICENSE NUMBER
WA8322562Medicaid
WA0141992OtherLABOR AND INDUSTRY
970016659OtherRAILROAD MEDICARE
WA0141992OtherLABOR AND INDUSTRY
WA8322562Medicaid
WA0001259300Medicare PIN