Provider Demographics
NPI:1558341420
Name:ALLEN, MARK EDWARD
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2907
Mailing Address - Country:US
Mailing Address - Phone:703-766-9737
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:800 INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6005
Practice Address - Country:US
Practice Address - Phone:757-363-6230
Practice Address - Fax:757-363-6204
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11919377OtherCAQH
VA11919377OtherCAQH