Provider Demographics
NPI:1881679900
Name:MOGENSEN, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MOGENSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:IA
Mailing Address - Zip Code:51450-7474
Mailing Address - Country:US
Mailing Address - Phone:712-657-8555
Mailing Address - Fax:712-657-2002
Practice Address - Street 1:1160 3RD ST
Practice Address - Street 2:
Practice Address - City:LAKE VIEW
Practice Address - State:IA
Practice Address - Zip Code:51450-7474
Practice Address - Country:US
Practice Address - Phone:712-657-8555
Practice Address - Fax:712-657-2002
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001660363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical