Provider Demographics
NPI:1003682410
Name:WOOD, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 VAN NUYS BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:661-360-6380
Practice Address - Street 1:5000 VAN NUYS BLVD STE 205
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1717
Practice Address - Country:US
Practice Address - Phone:818-850-2243
Practice Address - Fax:661-360-6380
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant