Healthcare Provider Details

I. General information

NPI: 1649223959
Provider Name (Legal Business Name): MARK ELLIOTT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 20 WEST
PALATKA FL
32177
US

IV. Provider business mailing address

200 CORPORATE BLVD SUITE 200
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 352-347-7920
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2014-0079
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA2581
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: