Provider Demographics
NPI:1801840095
Name:SCHULTHESS, MARK DUSTON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DUSTON
Last Name:SCHULTHESS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:ROUTE 12 BLDG 449
Mailing Address - Street 2:NAVAL AMBULATORY CARE CENTER ATTN PROFESSIONAL AFFAIRS
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5600
Mailing Address - Country:US
Mailing Address - Phone:860-694-2377
Mailing Address - Fax:860-694-2590
Practice Address - Street 1:ROUTE 12 BLDG 449
Practice Address - Street 2:NAVAL AMBULATORY CARE CENTER ATTN PROFESSIONAL AFFAIRS
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5600
Practice Address - Country:US
Practice Address - Phone:860-694-2377
Practice Address - Fax:860-694-2590
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT000190363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN