Healthcare Provider Details

I. General information

NPI: 1114445590
Provider Name (Legal Business Name): MARK A STANDLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 04/08/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W 21ST ST SAME DAY CARE CLINIC - CLOVIS
CLOVIS NM
88101-2011
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-769-7577
  • Fax: 505-769-6374
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0080
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: