Healthcare Provider Details

I. General information

NPI: 1205964939
Provider Name (Legal Business Name): MARK CROSS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2426 N MERRITT CREEK LOOP STE A
COEUR D ALENE ID
83814-4961
US

IV. Provider business mailing address

PO BOX 3687
COEUR D ALENE ID
83816-2529
US

V. Phone/Fax

Practice location:
  • Phone: 208-819-2183
  • Fax: 208-209-6063
Mailing address:
  • Phone: 208-819-2183
  • Fax: 208-209-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1548
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: