Provider Demographics
NPI:1922189075
Name:GENERO, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GENERO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 W MILLS ST
Practice Address - Street 2:STE A
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-9450
Practice Address - Country:US
Practice Address - Phone:828-894-3718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05876363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922189075Medicaid
SC2372PAMedicaid
SC2372PAMedicaid