Provider Demographics
NPI:1275510638
Name:BENDER, MARK C (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:BENDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:6737 W WASHINGTON ST STE 2210
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5650
Mailing Address - Country:US
Mailing Address - Phone:414-301-6381
Mailing Address - Fax:
Practice Address - Street 1:4650 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-5908
Practice Address - Country:US
Practice Address - Phone:414-376-5577
Practice Address - Fax:414-762-9927
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1135-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42991900Medicaid
WI0065Medicare ID - Type Unspecified
WI002001473Medicare PIN
WI42991900Medicaid
WI0072Medicare PIN