Provider Demographics
NPI:1144394693
Name:WILBUR, MARK EDWARD (PAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:WILBUR
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:700 NORTH SPRING
Mailing Address - City:CALIENTE
Mailing Address - State:NV
Mailing Address - Zip Code:89008-1010
Mailing Address - Country:US
Mailing Address - Phone:775-726-3121
Mailing Address - Fax:775-726-3666
Practice Address - Street 1:700 NORTH SPRING
Practice Address - Street 2:
Practice Address - City:CALIENTE
Practice Address - State:NV
Practice Address - Zip Code:89008-1010
Practice Address - Country:US
Practice Address - Phone:775-726-3121
Practice Address - Fax:775-726-3666
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA854363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506761Medicaid
NV100500Medicare ID - Type Unspecified
Q40726Medicare UPIN
NVBD890ZMedicare PIN