Provider Demographics
NPI:1275793978
Name:KLABO, MARK W (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:KLABO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:570 CHAUTAUQUA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3145
Mailing Address - Country:US
Mailing Address - Phone:701-845-6400
Mailing Address - Fax:701-845-6466
Practice Address - Street 1:570 CHAUTAUQUA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3145
Practice Address - Country:US
Practice Address - Phone:701-845-6400
Practice Address - Fax:701-845-6466
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NDPAC0391363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDPAC0391OtherLICENSE