Provider Demographics
NPI:1710964812
Name:FORD, MARK STEVENS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:STEVENS
Last Name:FORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 WELLFORD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3176
Mailing Address - Country:US
Mailing Address - Phone:540-361-1830
Mailing Address - Fax:540-361-1829
Practice Address - Street 1:2800 WELLFORD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3176
Practice Address - Country:US
Practice Address - Phone:540-361-1830
Practice Address - Fax:540-361-1829
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001015363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
4330530001OtherDMERC
P06294Medicare UPIN
VA000190O12Medicare ID - Type Unspecified
4330530001OtherDMERC