Provider Demographics
NPI:1104321397
Name:BLOCKER, MARK HAMPTON (PA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:HAMPTON
Last Name:BLOCKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:11540 HWY 169
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-6803
Mailing Address - Country:US
Mailing Address - Phone:912-237-5540
Mailing Address - Fax:
Practice Address - Street 1:2150 PEACHFORD RD STE Q
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6539
Practice Address - Country:US
Practice Address - Phone:678-615-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant