Provider Demographics
NPI:1609104835
Name:GILLESPIE, MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8900 VAN WYCK EXPY
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2832
Mailing Address - Country:US
Mailing Address - Phone:570-441-5265
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2832
Practice Address - Country:US
Practice Address - Phone:718-206-6058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY013468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant