Provider Demographics
NPI:1760945877
Name:EBERHARD, MARK PETER (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PETER
Last Name:EBERHARD
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 1:3671 SOUTHWESTERN BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1749
Mailing Address - Country:US
Mailing Address - Phone:716-662-7008
Mailing Address - Fax:716-662-5226
Practice Address - Street 1:3671 SOUTHWESTERN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1749
Practice Address - Country:US
Practice Address - Phone:716-662-7008
Practice Address - Fax:716-662-5226
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY023400OtherLICENSE