Provider Demographics
NPI:1780220855
Name:MORELAND, MARK THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:MORELAND
Suffix:
Gender:M
Credentials:PA-C
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:389 COUNTY ROAD 3371
Mailing Address - Street 2:
Mailing Address - City:KEMPNER
Mailing Address - State:TX
Mailing Address - Zip Code:76539-3755
Mailing Address - Country:US
Mailing Address - Phone:719-439-9798
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-288-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant