Provider Demographics
NPI:1760506869
Name:MARKS, IAN W (PAC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:W
Last Name:MARKS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:544 N GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3311
Practice Address - Country:US
Practice Address - Phone:818-241-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001200363A00000X, 363AS0400X
CAPA51543363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P12015Medicare UPIN
VA005432U92Medicare ID - Type Unspecified
VA6147780002Medicare NSC
VAP12015Medicare UPIN
P12015Medicare UPIN