Provider Demographics
NPI:1699182030
Name:SIEBELS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SIEBELS
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 1:1850 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5448
Mailing Address - Country:US
Mailing Address - Phone:507-387-6519
Mailing Address - Fax:507-387-1680
Practice Address - Street 1:1850 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5448
Practice Address - Country:US
Practice Address - Phone:507-387-6519
Practice Address - Fax:507-387-1680
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist