Provider Demographics
NPI:1457733966
Name:GOYA, MARK TAKESHI (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TAKESHI
Last Name:GOYA
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 1:5500 KLUMP AVE APT 506
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-2537
Mailing Address - Country:US
Mailing Address - Phone:661-703-7918
Mailing Address - Fax:
Practice Address - Street 1:4502 E AVENUE S
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552-4480
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52595363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical