Provider Demographics
NPI:1649257502
Name:GARRETT, MARK JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JOSEPH
Last Name:GARRETT
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 1:119 PERIWINKLE DR
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1997
Mailing Address - Country:US
Mailing Address - Phone:270-351-9953
Mailing Address - Fax:
Practice Address - Street 1:2412 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7998
Practice Address - Country:US
Practice Address - Phone:270-763-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant