Provider Demographics
NPI:1689048068
Name:OHLENKAMP, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:OHLENKAMP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 BARKLEY CIR
Mailing Address - Street 2:BLDG. A
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7593
Mailing Address - Country:US
Mailing Address - Phone:239-275-8882
Mailing Address - Fax:
Practice Address - Street 1:4790 BARKLEY CIR
Practice Address - Street 2:BLDG. A
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7593
Practice Address - Country:US
Practice Address - Phone:239-275-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL16186200Medicaid
FLIM548YMedicare PIN