Provider Demographics
NPI:1265428759
Name:RAO, MARK R (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:RAO
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:NSPG 104 ENDICOTT ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923
Mailing Address - Country:US
Mailing Address - Phone:978-739-7700
Mailing Address - Fax:
Practice Address - Street 1:104 ENDICOTT ST.
Practice Address - Street 2:LL05
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923
Practice Address - Country:US
Practice Address - Phone:978-739-7700
Practice Address - Fax:978-739-7736
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1265428759Medicaid
MEAP153304OtherMEDICARE B - MMC
MEAP153304OtherMEDICARE B - MMC
MEAP153305Medicare PIN
MEP01068812Medicare PIN
P38975Medicare UPIN
MEAP153306Medicare PIN