Provider Demographics
NPI:1366623886
Name:CHOQUETTE, MARK EDWARD JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:CHOQUETTE
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:615 OZARK RD
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36310-2629
Practice Address - Country:US
Practice Address - Phone:334-585-1171
Practice Address - Fax:334-585-1182
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA536363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1076470OtherNCCPA
AL125758Medicaid
ALPA536OtherSTATE LICENSE
ALPA536OtherSTATE LICENSE