Provider Demographics
NPI:1164685632
Name:FAN, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
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 741
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-0741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:425-999-4858
Practice Address - Street 1:1515 116TH AVE NE STE 205
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3811
Practice Address - Country:US
Practice Address - Phone:310-866-3707
Practice Address - Fax:425-999-4858
Is Sole Proprietor?:No
Enumeration Date:2008-07-05
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60122545207V00000X
CAA112478207V00000X
NYNOT YET207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0264461OtherSTATE L&I
WAG8892790Medicare PIN