Provider Demographics
NPI:1528604956
Name:BELILL, MARK ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:BELILL
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:PO BOX 1094
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-1094
Mailing Address - Country:US
Mailing Address - Phone:505-515-5714
Mailing Address - Fax:
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2706
Practice Address - Country:US
Practice Address - Phone:505-272-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2019-0103207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease