Provider Demographics
NPI:1346601929
Name:BROWN, MARK STEPHEN (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4332 TEETER TOTTER CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-2937
Mailing Address - Country:US
Mailing Address - Phone:719-661-4834
Mailing Address - Fax:
Practice Address - Street 1:4332 TEETER TOTTER CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-2937
Practice Address - Country:US
Practice Address - Phone:719-661-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant