Provider Demographics
NPI:1841365319
Name:FARNUM, MARK STEVEN (PAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:FARNUM
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 1:1020 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-586-7706
Mailing Address - Fax:
Practice Address - Street 1:50 TUPELO RD
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MA
Practice Address - Zip Code:02050-4427
Practice Address - Country:US
Practice Address - Phone:781-837-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1782Medicare ID - Type Unspecified
P66244Medicare UPIN