Provider Demographics
NPI:1629473723
Name:MARK-EKPENDU, ABIGAIL (PA)
Entity Type:Individual
Prefix:MS
First Name:ABIGAIL
Middle Name:
Last Name:MARK-EKPENDU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 PRASHER AVENUE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209
Mailing Address - Country:US
Mailing Address - Phone:209-330-1034
Mailing Address - Fax:
Practice Address - Street 1:4150 PATTERSON ROAD
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367
Practice Address - Country:US
Practice Address - Phone:209-863-3900
Practice Address - Fax:209-863-3999
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52004363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical