Provider Demographics
NPI:1578502779
Name:HENRY, MARK WILLIAM (MS, RPA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAM
Last Name:HENRY
Suffix:
Gender:M
Credentials:MS, RPA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S ORANGE AVE
Mailing Address - Street 2:C-LEVEL #1200
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2785
Mailing Address - Country:US
Mailing Address - Phone:973-972-6500
Mailing Address - Fax:973-972-9367
Practice Address - Street 1:205 S ORANGE AVE
Practice Address - Street 2:C-LEVEL #1200
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2785
Practice Address - Country:US
Practice Address - Phone:973-972-8240
Practice Address - Fax:973-972-9367
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015279363A00000X
1098952363A00000X
2255A2300X
NJ25MP00331900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
1098952OtherNCCPA
NY015279OtherPHYSICIAN ASSISTANT
NY015279OtherPHYSICIAN ASSISTANT