Provider Demographics
NPI:1801845722
Name:PANE, MARK A (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:PANE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3333 BROOKVIEW HILLS BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5661
Mailing Address - Country:US
Mailing Address - Phone:336-760-3007
Mailing Address - Fax:336-245-7715
Practice Address - Street 1:3333 BROOKVIEW HILLS BLVD STE 104
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5661
Practice Address - Country:US
Practice Address - Phone:336-760-3007
Practice Address - Fax:336-245-7715
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2019-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC104208363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1064084OtherNC CERTIFICATION OF PA