Provider Demographics
NPI:1619906971
Name:COLUCCI, MARK G (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:COLUCCI
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 1:17 SIDEWINDER RD
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-4756
Mailing Address - Country:US
Mailing Address - Phone:508-685-9038
Mailing Address - Fax:
Practice Address - Street 1:17 SIDEWINDER RD
Practice Address - Street 2:
Practice Address - City:EAST FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02536-4756
Practice Address - Country:US
Practice Address - Phone:508-685-9038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1101363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1503Medicare ID - Type UnspecifiedMEDICARE NUMBER
P36496Medicare UPIN