Provider Demographics
NPI:1841314705
Name:KEARNS, MARK ANDREW (PAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:KEARNS
Suffix:
Gender:M
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:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:SUNBURST
Mailing Address - State:MT
Mailing Address - Zip Code:59482-0035
Mailing Address - Country:US
Mailing Address - Phone:406-937-3610
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 67
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526-9705
Practice Address - Country:US
Practice Address - Phone:406-353-3100
Practice Address - Fax:406-353-3229
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT363363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT363OtherLICENSE
MT8HD505Medicare PIN
Q06228Medicare UPIN
MT363OtherLICENSE