Provider Demographics
NPI:1598323859
Name:CHAMBERS, MARK S
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:CHAMBERS
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:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:WA
Mailing Address - Zip Code:98610-0746
Mailing Address - Country:US
Mailing Address - Phone:360-904-4525
Mailing Address - Fax:
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:360-904-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60970556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty