Provider Demographics
NPI:1356778914
Name:SOUKUP, REED MARK (PA-C)
Entity type:Individual
Prefix:
First Name:REED
Middle Name:MARK
Last Name:SOUKUP
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 1:2001 S SHIELDS E101
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1872
Mailing Address - Country:US
Mailing Address - Phone:970-493-5334
Mailing Address - Fax:970-472-0638
Practice Address - Street 1:2001 S SHIELDS E101
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1872
Practice Address - Country:US
Practice Address - Phone:970-493-5334
Practice Address - Fax:970-472-0638
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO43322743Medicaid
CO341458YM8SMedicare PIN