Healthcare Provider Details

I. General information

NPI: 1740267160
Provider Name (Legal Business Name): MARK JUPINA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 POWERS BLVD
PARMA OH
44129-5437
US

IV. Provider business mailing address

PO BOX 931460
CLEVELAND OH
44193-1611
US

V. Phone/Fax

Practice location:
  • Phone: 440-743-3000
  • Fax:
Mailing address:
  • Phone: 440-879-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50-000867
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: