Provider Demographics
NPI:1154456069
Name:PENTA, MARK ANTHONY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:PENTA
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4745 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2067
Mailing Address - Country:US
Mailing Address - Phone:302-731-2888
Mailing Address - Fax:302-368-0103
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 225
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-731-2888
Practice Address - Fax:302-368-0103
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2011-11-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
DEC5-0000202363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE007065M88Medicare UPIN
DEP29532Medicare ID - Type Unspecified