Provider Demographics
NPI:1821310442
Name:WESCOTT, MARK (MPAS,PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WESCOTT
Suffix:
Gender:M
Credentials:MPAS,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6024 STORY MILL RD
Mailing Address - Street 2:
Mailing Address - City:KEYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30816-4532
Mailing Address - Country:US
Mailing Address - Phone:352-552-8828
Mailing Address - Fax:
Practice Address - Street 1:3485 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-771-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7803363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7803OtherGEORGIA COMPOSITE MEDICAL BOARD