Provider Demographics
NPI:1144798570
Name:PEDIGO, MARK DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:PEDIGO
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 1:2900 N I 35 STE 301
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-5146
Mailing Address - Country:US
Mailing Address - Phone:940-323-3426
Mailing Address - Fax:940-323-3427
Practice Address - Street 1:2900 N I 35 STE 301
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-5146
Practice Address - Country:US
Practice Address - Phone:940-323-3426
Practice Address - Fax:940-323-3427
Is Sole Proprietor?:No
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant