Healthcare Provider Details

I. General information

NPI: 1871619700
Provider Name (Legal Business Name): MARK M. FAULKNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 S LAMAR BLVD STE 100
SUNSET VALLEY TX
78745-1308
US

IV. Provider business mailing address

4715 S LAMAR BLVD STE 100
SUNSET VALLEY TX
78745-1308
US

V. Phone/Fax

Practice location:
  • Phone: 512-442-1996
  • Fax: 512-441-1093
Mailing address:
  • Phone: 512-442-1996
  • Fax: 512-441-1093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA02627
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: