Provider Demographics
NPI:1649434093
Name:FORTNEY, MARK M (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:FORTNEY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:6370 N STATE ROAD 7 STE 100
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-3606
Mailing Address - Country:US
Mailing Address - Phone:954-321-7762
Mailing Address - Fax:954-321-9596
Practice Address - Street 1:6370 N STATE ROAD 7 STE 100
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3606
Practice Address - Country:US
Practice Address - Phone:954-321-7762
Practice Address - Fax:954-321-9596
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2018-03-17
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Provider Licenses
StateLicense IDTaxonomies
FLPAT9104362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant