Provider Demographics
NPI:1376000869
Name:LIGHTOWLER, MARK EDWIN II (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWIN
Last Name:LIGHTOWLER
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 MAIN ST DEPT OF
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:203-362-3900
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST DEPT OF
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-392-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant