Provider Demographics
NPI:1184177297
Name:BELLIGAN, MARK (MPA, PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BELLIGAN
Suffix:
Gender:M
Credentials:MPA, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1122
Mailing Address - Country:US
Mailing Address - Phone:608-758-7215
Mailing Address - Fax:919-690-3246
Practice Address - Street 1:900 RIDGE ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1897
Practice Address - Country:US
Practice Address - Phone:608-873-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4882-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCU676AOtherMEDICARE PTAN