Provider Demographics
NPI:1689614729
Name:WILCOX, MARK EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:WILCOX
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:541 MAIN ST
Mailing Address - Street 2:SUITE 414
Mailing Address - City:SOUTH WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-1868
Mailing Address - Country:US
Mailing Address - Phone:781-952-1433
Mailing Address - Fax:508-630-2462
Practice Address - Street 1:541 MAIN ST
Practice Address - Street 2:SUITE 414
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-952-1433
Practice Address - Fax:508-630-2462
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAAP276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS26592Medicare UPIN
MAAP0273Medicare PIN