Provider Demographics
NPI:1669433652
Name:PEMBERTON, MARK LEE (PAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LEE
Last Name:PEMBERTON
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 KESSLER ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2553
Mailing Address - Country:US
Mailing Address - Phone:913-632-9480
Mailing Address - Fax:913-632-9499
Practice Address - Street 1:7450 KESSLER ST STE 202
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2553
Practice Address - Country:US
Practice Address - Phone:913-632-9480
Practice Address - Fax:913-632-9499
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500212363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSQ031082Medicare ID - Type Unspecified
KSR30300Medicare UPIN