Provider Demographics
NPI:1164671004
Name:WEBSTER, MARKO JOE (PA-C, DPT)
Entity Type:Individual
Prefix:
First Name:MARKO
Middle Name:JOE
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:PA-C, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-828-2880
Mailing Address - Fax:
Practice Address - Street 1:13060 ISLE DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8331
Practice Address - Country:US
Practice Address - Phone:218-828-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12204363A00000X
MN2544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant