Provider Demographics
NPI:1477659423
Name:VELARDE, MARK J (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:VELARDE
Suffix:
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 1:5300 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8632
Mailing Address - Country:US
Mailing Address - Phone:734-434-6262
Mailing Address - Fax:734-712-2820
Practice Address - Street 1:5300 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8632
Practice Address - Country:US
Practice Address - Phone:734-434-6262
Practice Address - Fax:734-712-2820
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004901363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1058112690OtherBCBS INDIVIDUAL
MI0H14989OtherBCBS GROUP
MI0H14989OtherBCBS GROUP
MIM86730018Medicare PIN
MIS57892Medicare UPIN