Provider Demographics
NPI:1508416785
Name:MARTINDALE, MARK CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:CHRISTOPHER
Last Name:MARTINDALE
Suffix:
Gender:
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 1:1717 LINCOLN WAY STE 108
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2556
Mailing Address - Country:US
Mailing Address - Phone:208-480-6174
Mailing Address - Fax:208-601-6174
Practice Address - Street 1:1717 LINCOLN WAY STE 108
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2556
Practice Address - Country:US
Practice Address - Phone:208-480-6174
Practice Address - Fax:208-601-6174
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2025-03-04
Deactivation Date:2025-02-13
Deactivation Code:
Reactivation Date:2025-02-24
Provider Licenses
StateLicense IDTaxonomies
ORPA-1937363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical