Provider Demographics
NPI:1942317938
Name:DEDMON, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEDMON
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:UTHSCSA, UTHSCSA, DEPT. OF SURGERY
Mailing Address - Street 2:7703 FLOYD CURL DRIVE, RM 238F.3
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-358-4000
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-257-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02389363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0Medicaid