Provider Demographics
NPI:1376511261
Name:OVERAS, MARK (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:OVERAS
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 1:1055 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-812-4673
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3260
Practice Address - Country:US
Practice Address - Phone:435-644-4100
Practice Address - Fax:435-644-3366
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2756363AM0700X
UT8663450-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ762931Medicaid
AZ762931Medicaid
AZP86345Medicare UPIN