Healthcare Provider Details

I. General information

NPI: 1093933673
Provider Name (Legal Business Name): EVELYN MARK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ EMERGENCY DEPARTMENT
BROOKLYN NY
11212-3139
US

IV. Provider business mailing address

80 MARCUS DR PROVIDER ENROLLMENT
MELVILLE NY
11747-4230
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-5180
  • Fax:
Mailing address:
  • Phone: 631-391-7889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007989
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: