Provider Demographics
NPI:1831109412
Name:MARCEWICZ, MARK L (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:MARCEWICZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5321
Mailing Address - Country:US
Mailing Address - Phone:850-878-2549
Mailing Address - Fax:850-878-9334
Practice Address - Street 1:1911 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5321
Practice Address - Country:US
Practice Address - Phone:850-878-2549
Practice Address - Fax:850-431-6341
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101256363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL SECURITY