Provider Demographics
NPI:1649688243
Name:OBERTHALER, MARK JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:OBERTHALER
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 1:504 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3534
Mailing Address - Country:US
Mailing Address - Phone:973-694-2690
Mailing Address - Fax:
Practice Address - Street 1:504 VALLEY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3534
Practice Address - Country:US
Practice Address - Phone:973-694-2690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-27
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJER25MP00337700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant