Provider Demographics
NPI:1891250502
Name:MECHAK, MARK BURDETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BURDETTE
Last Name:MECHAK
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 1:4520 MINUTEMAN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1252
Mailing Address - Country:US
Mailing Address - Phone:301-580-4418
Mailing Address - Fax:
Practice Address - Street 1:14535 JOHN MARSHALL HWY STE 105
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-4024
Practice Address - Country:US
Practice Address - Phone:703-754-0425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant