Provider Demographics
NPI:1134200470
Name:WINER, MARK R (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:WINER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4031 UPPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6819
Mailing Address - Country:US
Mailing Address - Phone:813-634-2733
Mailing Address - Fax:813-634-8606
Practice Address - Street 1:4031 UPPER CREEK DR
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6819
Practice Address - Country:US
Practice Address - Phone:813-634-2733
Practice Address - Fax:813-634-8606
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P37139Medicare UPIN
FLE5953YMedicare ID - Type Unspecified