Provider Demographics
NPI:1952386252
Name:ANDERSON, MARK NORMAN (PA C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NORMAN
Last Name:ANDERSON
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:PO BOX 4799
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35815-4799
Mailing Address - Country:US
Mailing Address - Phone:256-539-4545
Mailing Address - Fax:256-539-4990
Practice Address - Street 1:107 GOVERNORS DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-535-2300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA 099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL02004OtherB CROSS
ALS74181Medicare UPIN