Provider Demographics
NPI:1639622210
Name:HUNTLEY, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:HUNTLEY
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 1:123 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2652
Mailing Address - Country:US
Mailing Address - Phone:207-725-9065
Mailing Address - Fax:
Practice Address - Street 1:123 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:BRUSWICK
Practice Address - State:ME
Practice Address - Zip Code:04101-2652
Practice Address - Country:US
Practice Address - Phone:207-725-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant